Provider Demographics
NPI:1629063318
Name:SUNDARESH, MAMATHA (MD)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:SUNDARESH
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 1:977 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2919
Mailing Address - Country:US
Mailing Address - Phone:718-283-8015
Mailing Address - Fax:718-635-7235
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2844
Practice Address - Country:US
Practice Address - Phone:718-283-7500
Practice Address - Fax:718-635-7235
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190550208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01480813Medicaid
NY11-3563769OtherHORIZON HEALTHCARE NY
NY4604933OtherAETNA PPO
NYP2163738OtherOXFORD HEALTH PLANS
NY190550-F15OtherHEALTH FIRST
NY2698609OtherGHI
NY2563948OtherAETNA USHC HMO
NY300950401OtherHEALTH PLUS
NYBK00828-03OtherAMERICHOICE
NY2698609OtherGHI
NY4604933OtherAETNA PPO