Provider Demographics
NPI:1376504894
Name:SUNDARESAN, SANJOY (MD)
Entity type:Individual
Prefix:
First Name:SANJOY
Middle Name:
Last Name:SUNDARESAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4430
Mailing Address - Country:US
Mailing Address - Phone:940-767-0818
Mailing Address - Fax:940-763-8096
Practice Address - Street 1:1511 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4430
Practice Address - Country:US
Practice Address - Phone:940-767-0818
Practice Address - Fax:940-763-8096
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1083207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1336471-04Medicaid
TX1336471-04Medicaid
TXG32629Medicare UPIN