Provider Demographics
NPI:1326536202
Name:GOLAGABATHULA, SHARANYA
Entity Type:Individual
Prefix:
First Name:SHARANYA
Middle Name:
Last Name:GOLAGABATHULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 WEST OUTER DRIVE, SINAI GRACE HOSPITAL INTERNAL ME
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-966-1003
Mailing Address - Fax:313-966-1738
Practice Address - Street 1:6071 WEST OUTER DRIVE, SINAI GRACE HOSPITAL INTERNAL ME
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-966-1003
Practice Address - Fax:313-966-1738
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301503654207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program