Basic Information
| Provider Information | |||||||||
| NPI: | 1588768907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDARAM | ||||||||
| FirstName: | USHA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198990269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028367820 | ||||||||
| FaxNumber: | 3028367826 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 PEOPLES PLZ STE 200 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197025708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028367820 | ||||||||
| FaxNumber: | 3028367826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 04/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | C1-0012057 | DE | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 010023165 541581185 | 05 | VA | MEDICAID | C09463 | 01 | VA | GROUP PTAN | OTHER | C09633 | 01 | VA | GROUP PTAN | OTHER |