Provider Demographics
NPI:1376333716
Name:SUNDARAM, SUBISHA
Entity type:Individual
Prefix:
First Name:SUBISHA
Middle Name:
Last Name:SUNDARAM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17280 NW TUCSON ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 SW JEFFERSON AVE
Practice Address - Street 2:203 PHARMACY BUILDING
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8656
Practice Address - Country:US
Practice Address - Phone:541-737-3424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program