Provider Demographics
NPI:1669469193
Name:SUNDARAM, C.M.M. (MD)
Entity Type:Individual
Prefix:
First Name:C.M.M.
Middle Name:
Last Name:SUNDARAM
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 1:2600 N MAYFAIR ROAD
Mailing Address - Street 2:STE 670
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-933-9851
Mailing Address - Fax:414-933-1050
Practice Address - Street 1:2600 N MAYFAIR ROAD
Practice Address - Street 2:STE 670
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-933-9851
Practice Address - Fax:414-933-1050
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21941207R00000X, 207RG0100X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30317000Medicaid
000046365OtherMEDICARE UPIN
D33594Medicare UPIN
WI30317000Medicaid