Basic Information
| Provider Information | |||||||||
| NPI: | 1649250895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARMA | ||||||||
| FirstName: | SANJEEV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417327850 | ||||||||
| FaxNumber: | 5417327851 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 ROYAL AVE | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417327850 | ||||||||
| FaxNumber: | 5417327851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2006 | ||||||||
| LastUpdateDate: | 05/10/2010 | ||||||||
| 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 | 208G00000X | 35-088274 | OH | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 00G85988 | 05 | CA | MEDICAID | 364004 | 01 | OH | WELLCARE | OTHER | 751011 | 01 | OH | BUCKEYE | OTHER | 000000503671 | 01 | OH | ANTHEM | OTHER | 000000221392 | 01 | OH | UNISON | OTHER | 2695650 | 05 | OH | MEDICAID | 7164035 | 01 | OH | AETNA | OTHER |