Provider Demographics
NPI:1760555007
Name:SUNDARAM, RAGHUNANDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGHUNANDAN
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 1:7 RENEE CT
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3634
Mailing Address - Country:US
Mailing Address - Phone:732-662-1403
Mailing Address - Fax:
Practice Address - Street 1:817 RAHWAY AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-2212
Practice Address - Country:US
Practice Address - Phone:908-355-7365
Practice Address - Fax:908-355-2452
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07433200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4544682Medicaid
MI4544682Medicaid