Healthcare Provider Details

I. General information

NPI: 1588768907
Provider Name (Legal Business Name): USHA SUNDARAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 FETTLER PARK DR
DUMFRIES VA
22025-2050
US

IV. Provider business mailing address

3700 FETTLER PARK DR
DUMFRIES VA
22025-2050
US

V. Phone/Fax

Practice location:
  • Phone: 703-441-7500
  • Fax: 703-441-7696
Mailing address:
  • Phone: 703-441-7500
  • Fax: 703-441-7696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC1-0012057
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101054623
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: