Provider Demographics
NPI:1376790733
Name:SUNDARESHAN, VIDYA (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:SUNDARESHAN
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:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-9537
Mailing Address - Fax:217-545-8025
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4909
Practice Address - Country:US
Practice Address - Phone:217-545-9537
Practice Address - Fax:217-545-8025
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121672207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121672Medicaid
ILR03606Medicare PIN