Healthcare Provider Details

I. General information

NPI: 1033199401
Provider Name (Legal Business Name): VIVEK K. SHARMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 US HIGHWAY 30 W STE D
FORT WAYNE IN
46818-9701
US

IV. Provider business mailing address

PO BOX 80070
FORT WAYNE IN
46898-0070
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-1568
  • Fax: 260-432-4969
Mailing address:
  • Phone: 260-432-1568
  • Fax: 260-432-4969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01064449A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number01064449A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: