Provider Demographics
NPI:1215245253
Name:MUTYAM V. SHARMA, PSC
Entity type:Organization
Organization Name:MUTYAM V. SHARMA, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MUTYAM
Authorized Official - Middle Name:V
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:PSC
Authorized Official - Phone:502-635-6321
Mailing Address - Street 1:P.O. BOX 32513
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40232
Mailing Address - Country:US
Mailing Address - Phone:502-625-6321
Mailing Address - Fax:502-637-6386
Practice Address - Street 1:2909 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-625-6321
Practice Address - Fax:502-637-6386
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUTYAM V. SHARMA, PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17798208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64177983Medicaid
KY64177983Medicaid
KY1134701Medicare PIN