Healthcare Provider Details

I. General information

NPI: 1467548297
Provider Name (Legal Business Name): SOUTH BAY ORTHOPEDIC AND SPORTS MEDICINE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 OCONNOR DR
SAN JOSE CA
95128-1623
US

IV. Provider business mailing address

2386 BENTLEY RIDGE DR
SAN JOSE CA
95138-2435
US

V. Phone/Fax

Practice location:
  • Phone: 408-376-3380
  • Fax:
Mailing address:
  • Phone: 530-294-1136
  • Fax: 530-294-1143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA85279
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberH27947
License Number StateCA

VIII. Authorized Official

Name: DR. SAMIR SHARMA
Title or Position: OWNER
Credential: M.D.
Phone: 408-376-3380