Healthcare Provider Details

I. General information

NPI: 1386855435
Provider Name (Legal Business Name): SOMA SUNDARAM AVVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 PHILADELPHIA DR 651
DAYTON OH
45406-1840
US

IV. Provider business mailing address

5770 WILLOW WALK
DAYTON OH
45415-2620
US

V. Phone/Fax

Practice location:
  • Phone: 937-278-0809
  • Fax: 937-275-2696
Mailing address:
  • Phone: 937-275-5600
  • Fax: 937-275-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.37830
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: