Provider Demographics
NPI:1225334840
Name:PARVATHANENI, SHARMILA (MD)
Entity Type:Individual
Prefix:
First Name:SHARMILA
Middle Name:
Last Name:PARVATHANENI
Suffix:
Gender:F
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:PO BOX 3837
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86402-3837
Mailing Address - Country:US
Mailing Address - Phone:928-718-0777
Mailing Address - Fax:928-718-0877
Practice Address - Street 1:2901 N STOCKTON HILL RD STE B
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:US
Practice Address - Phone:928-718-0777
Practice Address - Fax:928-718-0877
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126682207R00000X
AZ49359207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1225334840Medicaid