Provider Demographics
NPI:1518110287
Name:SUNDARAM FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:SUNDARAM FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAWAHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDRARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-234-6300
Mailing Address - Street 1:987 W VERNON AVE AND
Mailing Address - Street 2:10410 LOWER AZUSA RD #101 EL MONTE CA 91731
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3038
Mailing Address - Country:US
Mailing Address - Phone:323-234-6300
Mailing Address - Fax:
Practice Address - Street 1:987 W. VERNON AVE AND
Practice Address - Street 2:10410 LOWER AZUSA RD #104 EL MONTE CA. 91731
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3038
Practice Address - Country:US
Practice Address - Phone:323-234-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67659174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty