Healthcare Provider Details

I. General information

NPI: 1386627065
Provider Name (Legal Business Name): SURESH V. UNDAVIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2005
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 CLAYTON AVE
VESTAL NY
13850-2430
US

IV. Provider business mailing address

PO BOX 645 114 CLAYTON AVENUE
VESTAL NY
13850-0645
US

V. Phone/Fax

Practice location:
  • Phone: 607-785-4277
  • Fax: 607-785-3617
Mailing address:
  • Phone: 607-785-4277
  • Fax: 607-785-3617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberNY122304
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number122304
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number122304
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number122304
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number122304
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number122304
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number122304
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: