Basic Information
Provider Information | |||||||||
NPI: | 1033199401 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHARMA | ||||||||
FirstName: | VIVEK | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 80070 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468980070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604321568 | ||||||||
FaxNumber: | 2604324969 | ||||||||
Practice Location | |||||||||
Address1: | 5001 US HIGHWAY 30 W STE D | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468189701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604321568 | ||||||||
FaxNumber: | 2604324969 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2006 | ||||||||
LastUpdateDate: | 06/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01064449A | IN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 01064449A | IN | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
ID | Type | State | Issuer | Description | 201063720 | 05 | IN |   | MEDICAID | 1033199401 | 05 | MI |   | MEDICAID | 0068589 | 05 | OH |   | MEDICAID | 0157031 | 05 | NJ |   | MEDICAID |