Provider Demographics
NPI:1013178623
Name:PUTTICHANDA, SHARATH PONNAPPA
Entity Type:Individual
Prefix:
First Name:SHARATH
Middle Name:PONNAPPA
Last Name:PUTTICHANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 UNION ST
Mailing Address - Street 2:APARTMENT 610
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-1790
Mailing Address - Country:US
Mailing Address - Phone:917-675-1997
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6346
Practice Address - Fax:401-455-6532
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD139082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry