Provider Demographics
NPI:1497140362
Name:SONDERGARD, JULIA KONSTANTINOVNA (DO)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:KONSTANTINOVNA
Last Name:SONDERGARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:K
Other - Last Name:RUSINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-3477
Practice Address - Fax:937-641-5410
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014501207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0409456Medicaid