Provider Demographics
NPI:1871029819
Name:DAMODHARAN, SUDARSHAWN
Entity Type:Individual
Prefix:
First Name:SUDARSHAWN
Middle Name:
Last Name:DAMODHARAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 HERMITAGE LN
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-4032
Mailing Address - Country:US
Mailing Address - Phone:224-622-7871
Mailing Address - Fax:
Practice Address - Street 1:UW HOSPITALS AND CLINICS
Practice Address - Street 2:600 HIGHLAND AVE
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7052621208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program