Provider Demographics
NPI:1831462464
Name:RAKESH SHARMA PHYSICIAN PC
Entity Type:Organization
Organization Name:RAKESH SHARMA PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-588-8393
Mailing Address - Street 1:122 PORTION RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4174
Mailing Address - Country:US
Mailing Address - Phone:631-588-8393
Mailing Address - Fax:631-588-2312
Practice Address - Street 1:122 PORTION RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4174
Practice Address - Country:US
Practice Address - Phone:631-588-8393
Practice Address - Fax:631-588-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161670207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01110154Medicaid
NY01110154Medicaid