Provider Demographics
NPI:1841278983
Name:SUNDARESAN, MYTHILI (MD)
Entity type:Individual
Prefix:MRS
First Name:MYTHILI
Middle Name:
Last Name:SUNDARESAN
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:PO BOX 1514
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93275
Mailing Address - Country:US
Mailing Address - Phone:559-635-7100
Mailing Address - Fax:559-635-7104
Practice Address - Street 1:231 W NOBLE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-2631
Practice Address - Country:US
Practice Address - Phone:559-635-7100
Practice Address - Fax:559-635-7104
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4037502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A403750Medicaid
CA00A403750Medicare PIN
CA00A403750Medicaid