Provider Demographics
NPI:1003811340
Name:HEGDE, SUNIL KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNIL
Middle Name:KUMAR
Last Name:HEGDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S. RAYMOND AVE.
Mailing Address - Street 2:SUITE #120
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:626-403-1444
Mailing Address - Fax:626-403-1448
Practice Address - Street 1:630 S. RAYMOND AVE.
Practice Address - Street 2:SUITE #120
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105
Practice Address - Country:US
Practice Address - Phone:626-403-1444
Practice Address - Fax:626-403-1448
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-10-11
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
CAA45472208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A454720Medicaid
CAA45472OtherBLUE CROSS OF CALIFORNIA
CAE40893Medicare UPIN