Provider Demographics
NPI:1447870977
Name:SHANMUGASUNDARAM, VENKATACHALAM
Entity type:Organization
Organization Name:SHANMUGASUNDARAM, VENKATACHALAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:V S
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-798-6767
Mailing Address - Street 1:10131 W FOREST HILL BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6109
Mailing Address - Country:US
Mailing Address - Phone:561-798-6767
Mailing Address - Fax:561-795-2706
Practice Address - Street 1:10131 W FOREST HILL BLVD STE 201
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6109
Practice Address - Country:US
Practice Address - Phone:561-798-6767
Practice Address - Fax:561-795-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL61449OtherBLUE CROSS BLUE SHIELD
FL00446OtherSTAYWELL
FL040885901Medicaid
FL1002118OtherUNITED HEALTH CARE
FL00446OtherWELLCARE
FL3370WELLOtherNEIGHBORHOOD PARTNERS
0854223OtherAETNA
FL0067235OtherGHI