Provider Demographics
NPI:1437714656
Name:SHARMA, KANISHK DEEP
Entity Type:Individual
Prefix:
First Name:KANISHK
Middle Name:DEEP
Last Name:SHARMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 FAIRFAX AVENUE EASTERN VIRGINIA MEDICAL SCHOOL INTE
Mailing Address - Street 2:SUITE 445
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507
Mailing Address - Country:US
Mailing Address - Phone:757-446-8920
Mailing Address - Fax:
Practice Address - Street 1:825 FAIRFAX AVENUE EASTERN VIRGINIA MEDICAL SCHOOL INTE
Practice Address - Street 2:SUITE 445
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507
Practice Address - Country:US
Practice Address - Phone:757-446-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101274457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program