Provider Demographics
NPI:1114022910
Name:SHARMA, SURYA KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SURYA
Middle Name:KUMAR
Last Name:SHARMA
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 1:1312 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2718
Mailing Address - Country:US
Mailing Address - Phone:719-544-2090
Mailing Address - Fax:719-544-2094
Practice Address - Street 1:1805 AQUILA DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2617
Practice Address - Country:US
Practice Address - Phone:719-544-4765
Practice Address - Fax:719-544-2094
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41617208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33432031Medicaid
CO33432031Medicaid