Provider Demographics
NPI:1912318247
Name:MALATHY T SUNDARAM M.D, LLC
Entity Type:Organization
Organization Name:MALATHY T SUNDARAM M.D, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MALATHY
Authorized Official - Middle Name:T
Authorized Official - Last Name:SUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-850-1079
Mailing Address - Street 1:312 COTTAGE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-1817
Mailing Address - Country:US
Mailing Address - Phone:207-850-1079
Mailing Address - Fax:207-324-0911
Practice Address - Street 1:312 COTTAGE ST STE A
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-1817
Practice Address - Country:US
Practice Address - Phone:207-850-1079
Practice Address - Fax:207-324-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD16273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3087980Medicaid
MEME0202Medicare UPIN