Provider Demographics
NPI:1447459052
Name:SUNDARAMOORTHY, KAVETHA (MD)
Entity type:Individual
Prefix:DR
First Name:KAVETHA
Middle Name:
Last Name:SUNDARAMOORTHY
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 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-647-4746
Mailing Address - Fax:860-647-6809
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-647-4746
Practice Address - Fax:860-647-6809
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86002084P0804X
CT0502432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004041885Medicaid
CT004025177Medicaid
CT004025177Medicaid
CT004041885Medicaid
CTD400144122Medicare PIN