Provider Demographics
NPI:1386627065
Name:UNDAVIA, SURESH V (MD)
Entity Type:Individual
Prefix:MR
First Name:SURESH
Middle Name:V
Last Name:UNDAVIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:114 CLAYTON AVENUE
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-0645
Mailing Address - Country:US
Mailing Address - Phone:607-785-4277
Mailing Address - Fax:607-785-3617
Practice Address - Street 1:114 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2430
Practice Address - Country:US
Practice Address - Phone:607-785-4277
Practice Address - Fax:607-785-3617
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-27
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223042084F0202X, 2084N0400X, 2084P0802X, 2084P0805X, 2084P0800X, 207L00000X
NYNY122304207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYOO577399Medicaid
NYSU35020BMedicare ID - Type UnspecifiedM.D.