Provider Demographics
NPI:1114924735
Name:SUNDARAM, MAGESH (MD)
Entity Type:Individual
Prefix:DR
First Name:MAGESH
Middle Name:
Last Name:SUNDARAM
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:PO BOX 64226
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4226
Mailing Address - Country:US
Mailing Address - Phone:667-214-1734
Mailing Address - Fax:410-706-6976
Practice Address - Street 1:14999 HEALTH CENTER DR STE 201
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1087
Practice Address - Country:US
Practice Address - Phone:667-214-1718
Practice Address - Fax:410-328-5147
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0004534208600000X, 208600000X
IL0361305842086X0206X
MDD00526272086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00266429OtherRAILROAD MEDICARE
36066OtherNCI INVESTIGATOR ID
MD004733300Medicaid
PA1014359720001Medicaid
OH2598694Medicaid
WV3810003244Medicaid
KY64106016Medicaid
WV3810003244Medicaid
WVSU6033511Medicare PIN
ILIL3270681Medicare PIN