Provider Demographics
NPI:1114010477
Name:SUNDARAM, PALANISAMY S I (MD)
Entity Type:Individual
Prefix:DR
First Name:PALANISAMY
Middle Name:S
Last Name:SUNDARAM
Suffix:I
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 1:860 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3601
Mailing Address - Country:US
Mailing Address - Phone:973-399-8650
Mailing Address - Fax:973-533-4470
Practice Address - Street 1:860 GROVE ST
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3601
Practice Address - Country:US
Practice Address - Phone:973-399-8650
Practice Address - Fax:973-533-4470
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02857500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics