Basic Information
| Provider Information | |||||||||
| NPI: | 1629039052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANEGUNDI | ||||||||
| FirstName: | SUDHINDRA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 631 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709629977 | ||||||||
| FaxNumber: | 7703399804 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709629977 | ||||||||
| FaxNumber: | 7703399804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 017970 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000363998F | 05 | GA | MEDICAID |