Provider Demographics
NPI:1669820858
Name:SUNDARESON, MOHAN (MD,)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:
Last Name:SUNDARESON
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 1:1638, SOUTH GRANT STREET
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402
Mailing Address - Country:US
Mailing Address - Phone:650-571-6283
Mailing Address - Fax:650-571-6283
Practice Address - Street 1:1638 SOUTH GRANT ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402
Practice Address - Country:US
Practice Address - Phone:650-571-6283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40596208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics