Provider Demographics
NPI:1821083031
Name:SHANMUGASUNDARAM, VENKATACHALAM (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATACHALAM
Middle Name:
Last Name:SHANMUGASUNDARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:V.S.
Other - Middle Name:
Other - Last Name:SUNDARAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10131 W FOREST HILL BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6109
Mailing Address - Country:US
Mailing Address - Phone:561-798-6767
Mailing Address - Fax:561-795-2706
Practice Address - Street 1:10131 W FOREST HILL BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6156
Practice Address - Country:US
Practice Address - Phone:561-798-6767
Practice Address - Fax:561-795-2706
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045705207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00446OtherWELLCARE
FL3370WELLOtherNIEGHBORHOOD PATNERS
FL592607590OtherCHAMPUS
FL0067235OtherGHI
FL1002118OtherUNITED HEALTHCARE
FL3370WELLOtherNEIGHBORHOOD PARTNERS
FL00446OtherSTAYWELL
FL592607590OtherVISTA
FL205868OtherAMERIGROUP
FL61449OtherBLUE CROSS BLUE SHIELD
FL040885901Medicaid
FL0854223OtherAETNA
FL592607590AOtherHUMANA
FL61449OtherBLUE CROSS BLUE SHIELD
FL1002118OtherUNITED HEALTHCARE