Provider Demographics
NPI:1669438339
Name:SUNDARUM, SRINI V (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:SRINI
Middle Name:V
Last Name:SUNDARUM
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 S 23RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1605
Mailing Address - Country:US
Mailing Address - Phone:253-272-9994
Mailing Address - Fax:253-572-0468
Practice Address - Street 1:3315 S 23RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1605
Practice Address - Country:US
Practice Address - Phone:253-272-9994
Practice Address - Fax:253-572-0468
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036043174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8225245Medicaid
WA04563177OtherECFMG
WAMD00036043OtherSTATE LICENSE
WA121911OtherLABOR & INDUSTRIES
WA8225245Medicaid
WABS4125983OtherDEA
WA8225245Medicaid