Provider Demographics
NPI:1356460166
Name:SHARMA, MUTYAM V (MD)
Entity Type:Individual
Prefix:
First Name:MUTYAM
Middle Name:V
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:PO BOX 32513
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40232
Mailing Address - Country:US
Mailing Address - Phone:502-635-6321
Mailing Address - Fax:502-637-6386
Practice Address - Street 1:2909 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-635-6321
Practice Address - Fax:502-637-6386
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17798208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1059052OtherPASSPORT
KY64177983Medicaid
KY000000045870OtherANTHEM
KY000000045870OtherANTHEM
KY64177983Medicaid