Provider Demographics
NPI:1043201189
Name:BAGLA, SHARWAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHARWAN
Middle Name:K
Last Name:BAGLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-2706
Mailing Address - Country:US
Mailing Address - Phone:631-269-5550
Mailing Address - Fax:631-269-6304
Practice Address - Street 1:99 MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-2706
Practice Address - Country:US
Practice Address - Phone:631-269-5550
Practice Address - Fax:631-269-6304
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127799207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY418222Medicaid
06A921Medicare ID - Type Unspecified
NY418222Medicaid