Provider Demographics
NPI:1316041684
Name:SHARMA, SURENDRA KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SURENDRA
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 1:4020 W FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-5279
Mailing Address - Country:US
Mailing Address - Phone:951-652-3300
Mailing Address - Fax:951-765-6133
Practice Address - Street 1:4020 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-5279
Practice Address - Country:US
Practice Address - Phone:951-652-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48320208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A483200Medicaid
E57074Medicare UPIN
00A483200Medicare ID - Type Unspecified