Provider Demographics
NPI:1518930437
Name:KAMALESON, SUNDERRAJ MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNDERRAJ
Middle Name:MARK
Last Name:KAMALESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E DERENNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:210 E DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6736
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:912-644-5280
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25383207X00000X
GA042622207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000732828BMedicaid
GAG43467Medicare UPIN
GA20NCCMCMedicare ID - Type Unspecified
GA000732828BMedicaid