Provider Demographics
NPI:1740551688
Name:BASU, SHARMILA (MD,)
Entity type:Individual
Prefix:
First Name:SHARMILA
Middle Name:
Last Name:BASU
Suffix:
Gender:F
Credentials:MD,
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 VANDEVER AVE
Mailing Address - Street 2:KAISER PERMANENTE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3315
Mailing Address - Country:US
Mailing Address - Phone:619-528-5000
Mailing Address - Fax:618-528-5000
Practice Address - Street 1:4405 VANDEVER AVE
Practice Address - Street 2:KAISER PERMANENTE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3315
Practice Address - Country:US
Practice Address - Phone:619-528-5000
Practice Address - Fax:618-528-5000
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA113278390200000X
CAA120703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113278OtherSID # 113278
CAA120703OtherMEDICAL BOARD OF CALIFORNIA