Provider Demographics
NPI:1992039473
Name:SUNDARAM FAMILY MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:SUNDARAM FAMILY MEDICAL CLINIC INC.
Other - Org Name:SUNDARAM FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAWAHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-699-5888
Mailing Address - Street 1:9217 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-2450
Mailing Address - Country:US
Mailing Address - Phone:562-699-5888
Mailing Address - Fax:562-699-2955
Practice Address - Street 1:9217 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2450
Practice Address - Country:US
Practice Address - Phone:562-699-5888
Practice Address - Fax:562-699-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67659207Q00000X
CAA92178207Q00000X
CAPA15565207Q00000X
CAPA19004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21327Medicaid
CAPA21547Medicaid
CA20A7566Medicaid