Provider Demographics
NPI:1396731865
Name:SUNDARAM, RAJENDRAN (MD)
Entity type:Individual
Prefix:
First Name:RAJENDRAN
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 1:5334 MEADOW LANE CT
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1469
Mailing Address - Country:US
Mailing Address - Phone:440-934-5454
Mailing Address - Fax:440-934-8999
Practice Address - Street 1:5172 LEAVITT RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-2384
Practice Address - Country:US
Practice Address - Phone:440-282-7420
Practice Address - Fax:440-282-9855
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH110185582OtherRR MEDICARE
OH2023367Medicaid
OH0863949Medicare PIN
OH0863941Medicare PIN
OH4052224Medicare PIN
OH4052223Medicare PIN
OH2023367Medicaid