Provider Demographics
NPI:1467548297
Name:SOUTH BAY ORTHOPEDIC AND SPORTS MEDICINE CLINIC, INC.
Entity Type:Organization
Organization Name:SOUTH BAY ORTHOPEDIC AND SPORTS MEDICINE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-376-3380
Mailing Address - Street 1:2386 BENTLEY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-2435
Mailing Address - Country:US
Mailing Address - Phone:530-294-1136
Mailing Address - Fax:530-294-1143
Practice Address - Street 1:333 OCONNOR DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1623
Practice Address - Country:US
Practice Address - Phone:408-376-3380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH27947207XX0005X
CAA85279208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH27947Medicare UPIN