Provider Demographics
NPI:1255315065
Name:SUNDER, THEODORE R (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:SUNDER
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 1:421 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5317
Mailing Address - Country:US
Mailing Address - Phone:217-757-6888
Mailing Address - Fax:217-757-6869
Practice Address - Street 1:421 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5317
Practice Address - Country:US
Practice Address - Phone:217-757-6888
Practice Address - Fax:217-757-6869
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0885382084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088538Medicaid
ILL82254Medicare ID - Type Unspecified
IL036088538Medicaid