Healthcare Provider Details

I. General information

NPI: 1043201189
Provider Name (Legal Business Name): SHARWAN K BAGLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MAIN ST
KINGS PARK NY
11754-2706
US

IV. Provider business mailing address

99 MAIN ST
KINGS PARK NY
11754-2706
US

V. Phone/Fax

Practice location:
  • Phone: 631-269-5550
  • Fax: 631-269-6304
Mailing address:
  • Phone: 631-269-5550
  • Fax: 631-269-6304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number127799
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: