Provider Demographics
NPI:1497739528
Name:SUNDARAM, MICHELE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:SUNDARAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:LYNN
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3428 GRIFFITH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1403
Mailing Address - Country:US
Mailing Address - Phone:323-661-8903
Mailing Address - Fax:
Practice Address - Street 1:2101 HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2003
Practice Address - Country:US
Practice Address - Phone:323-664-2931
Practice Address - Fax:323-664-8931
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A75660Medicaid
CA020A75660Medicaid
CAW20A7566AMedicare PIN