Provider Demographics
NPI:1164501185
Name:KUNCHAM, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:KUNCHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-5704
Mailing Address - Country:US
Mailing Address - Phone:516-379-2689
Mailing Address - Fax:516-867-3880
Practice Address - Street 1:2428 MERRICK RD
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5704
Practice Address - Country:US
Practice Address - Phone:516-379-2689
Practice Address - Fax:516-867-3880
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY84D771OtherMEDICARE ID#
NY84D77XYPW1Medicare PIN