Provider Demographics
NPI:1568650794
Name:SUNDARAM, NANDI (PT, MPT)
Entity Type:Individual
Prefix:
First Name:NANDI
Middle Name:
Last Name:SUNDARAM
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2492 WALNUT AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6953
Mailing Address - Country:US
Mailing Address - Phone:714-544-2188
Mailing Address - Fax:714-544-2189
Practice Address - Street 1:2492 WALNUT AVE STE 140
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6953
Practice Address - Country:US
Practice Address - Phone:714-544-2188
Practice Address - Fax:714-544-2189
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29433208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29433OtherSTATE LICENSE
CAPT29433OtherSTATE LICENSE