Basic Information
| Provider Information | |||||||||
| NPI: | 1841727427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDARESAN | ||||||||
| FirstName: | SWAMINATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 MAIN ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | ACTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017203301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783717010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 3RD AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024517549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817018030 | ||||||||
| FaxNumber: | 7813739248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2017 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 288136 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.