Provider Demographics
NPI:1760043970
Name:SHARMA, GAUTAM
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
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 1:7218 164TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4222
Mailing Address - Country:US
Mailing Address - Phone:718-969-6640
Mailing Address - Fax:
Practice Address - Street 1:7218 164TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-4222
Practice Address - Country:US
Practice Address - Phone:718-969-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019545207Q00000X
NY317425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine