Basic Information
| Provider Information | |||||||||
| NPI: | 1104055839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDARAM | ||||||||
| FirstName: | ABHISHEK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.B.B.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530249201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623291000 | ||||||||
| FaxNumber: | 2623291001 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530249201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623291000 | ||||||||
| FaxNumber: | 2623291001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 68978 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 68978 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.