Provider Demographics
NPI:1588645022
Name:SUNDARAM SUKUMAR MD PA
Entity Type:Organization
Organization Name:SUNDARAM SUKUMAR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SUNDARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-519-3131
Mailing Address - Street 1:2301 S CLEAR CREEK RD
Mailing Address - Street 2:#112
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4143
Mailing Address - Country:US
Mailing Address - Phone:254-519-3131
Mailing Address - Fax:254-519-3133
Practice Address - Street 1:2301 S CLEAR CREEK RD
Practice Address - Street 2:#112
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4143
Practice Address - Country:US
Practice Address - Phone:254-519-3131
Practice Address - Fax:254-519-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3239207R00000X
TXJ3626207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149340501Medicaid
TX149340501Medicaid