Provider Demographics
NPI:1548234321
Name:MANICKAM, SUNDARA K (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNDARA
Middle Name:K
Last Name:MANICKAM
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 1:5334 MEADOW LANE CT
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1469
Mailing Address - Country:US
Mailing Address - Phone:440-934-8921
Mailing Address - Fax:440-934-8938
Practice Address - Street 1:5334 MEADOW LANE CT
Practice Address - Street 2:
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1469
Practice Address - Country:US
Practice Address - Phone:440-934-8921
Practice Address - Fax:440-934-8938
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2481701Medicaid
OH2481701Medicaid
H06030Medicare UPIN