Provider Demographics
NPI:1932138583
Name:SUNDARAM, SHOBANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBANA
Middle Name:
Last Name:SUNDARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43184 DEQUINDRE RD
Mailing Address - Street 2:STE 208
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314
Mailing Address - Country:US
Mailing Address - Phone:586-731-1500
Mailing Address - Fax:586-731-1363
Practice Address - Street 1:43184 DEQUINDRE RD
Practice Address - Street 2:STE 208
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314
Practice Address - Country:US
Practice Address - Phone:586-731-1500
Practice Address - Fax:586-731-1363
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077847208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01004032OtherHEALTHPLUS COMMERCIAL
MI1010590OtherMCLAREN HEALTH PLAN
MI3502911592OtherBCBSM
MI4711851-10Medicaid
MI4558267-10Medicaid
MI200000005894OtherPHP COMMERCIAL
MA1010591OtherMCLAREN HEALTH PLAN