Individual
VICTOR JAYASUNDERA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RPT
Contact information
Practice address
23100 PROVIDENCE DR, SUITE 135, SOUTHFIELD, MI 48075-3646
(248) 905-5180
(248) 905-5181
Mailing address
23100 PROVIDENCE DR, SUITE 135, SOUTHFIELD, MI 48075-3646
(248) 905-5180
(248) 905-5181
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
5501005927
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5501005927
STATE LICENSE
MI
Enumeration date
03/23/2007
Last updated
01/26/2012
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