Provider Demographics
NPI:1760440655
Name:EL-AMIN, SUNDIATA M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNDIATA
Middle Name:M
Last Name:EL-AMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:CEPHAS
Other - Middle Name:G
Other - Last Name:JACKSON
Other - Suffix:SR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:557 WELLINGTON GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3477
Mailing Address - Country:US
Mailing Address - Phone:859-402-1517
Mailing Address - Fax:
Practice Address - Street 1:557 WELLINGTON GARDENS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3477
Practice Address - Country:US
Practice Address - Phone:859-402-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY21770OtherMEDICAL LIC
KYF20679Medicare UPIN