Healthcare Provider Details

I. General information

NPI: 1780112979
Provider Name (Legal Business Name): SHARANYA VISAKAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FAMILY PRACTICE DR
KINGSTON NY
12401-6449
US

IV. Provider business mailing address

396 BROADWAY
KINGSTON NY
12401-4626
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-6400
  • Fax: 845-339-7288
Mailing address:
  • Phone: 845-802-7600
  • Fax: 845-338-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberT0661
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01083794A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: