Provider Demographics
NPI:1235113663
Name:SARPA, J R NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:J R
Middle Name:NICHOLAS
Last Name:SARPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2920 S MCINTIRE DR
Practice Address - Street 2:SUITE 350
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-332-2226
Practice Address - Fax:812-339-2934
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038321A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100352470Medicaid
INM400056145Medicare PIN
INE67008Medicare UPIN