Healthcare Provider Details

I. General information

NPI: 1730138892
Provider Name (Legal Business Name): SHANKAR M SUNDARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 WOODMAN DR STE 320
DAYTON OH
45420-1171
US

IV. Provider business mailing address

3085 WOODMAN DR STE 320
DAYTON OH
45420-1164
US

V. Phone/Fax

Practice location:
  • Phone: 833-828-0838
  • Fax:
Mailing address:
  • Phone: 937-795-1090
  • Fax: 937-795-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35.140498
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301503585
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301503585
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberDR.0069648
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35.140498
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: