Basic Information
| Provider Information | |||||||||
| NPI: | 1477618528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARMA | ||||||||
| FirstName: | KUNJBALA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SHARMA | ||||||||
| OtherFirstName: | KUNJBALA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 39 EAST AVE | ||||||||
| Address2: | BLACKSTONE VALLEY COMMUNITY HEALTH CARE | ||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017220081 | ||||||||
| FaxNumber: | 4013120318 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017220081 | ||||||||
| FaxNumber: | 4013120318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 39079 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | 39079 | MA | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | MD07897 | RI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 400561 | 01 | RI | BC BS OF RI (BLUECHIP) | OTHER | 9765239 | 05 | MA | MEDICAID | 400561 | 01 | RI | BC BS OF RI | OTHER | 961244-01 | 01 | MA | NETWORK HEALTH | OTHER | E05285 | 01 | MA | BC BS OF MA | OTHER |