Provider Demographics
NPI:1669674073
Name:SANJOY SUNDARESAN MD PA
Entity Type:Organization
Organization Name:SANJOY SUNDARESAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJOY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDARESAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-767-0818
Mailing Address - Street 1:1511 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4430
Mailing Address - Country:US
Mailing Address - Phone:940-767-0818
Mailing Address - Fax:940-763-8096
Practice Address - Street 1:1511 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4430
Practice Address - Country:US
Practice Address - Phone:940-767-0818
Practice Address - Fax:940-763-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3111Medicare PIN