Provider Demographics
NPI:1518932524
Name:SUNDAR, BANU (MD,)
Entity Type:Individual
Prefix:
First Name:BANU
Middle Name:
Last Name:SUNDAR
Suffix:
Gender:F
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:WORCETER
Practice Address - State:MA
Practice Address - Zip Code:01655-2029
Practice Address - Country:US
Practice Address - Phone:508-856-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT603902084N0400X
MA2061242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2109522Medicaid
MAI43155Medicare UPIN
MANX3958Medicare PIN