Provider Demographics
NPI:1922057900
Name:SUNDARAM, BALASASIKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:BALASASIKUMAR
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 1:1543 FIANNA PLACE TER
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8582
Mailing Address - Country:US
Mailing Address - Phone:479-648-6714
Mailing Address - Fax:
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-441-5011
Practice Address - Fax:479-441-4932
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4251207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156990001Medicaid
AZE4251OtherARKANSAS STATE LICENSE
OK200117580AMedicaid
AZBS7443017OtherDEA
AZBS7443017OtherDEA