Healthcare Provider Details

I. General information

NPI: 1013178623
Provider Name (Legal Business Name): SHARATH PONNAPPA PUTTICHANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 BLACKSTONE BLVD
PROVIDENCE RI
02906-4800
US

IV. Provider business mailing address

150 UNION ST APARTMENT 610
PROVIDENCE RI
02903-1790
US

V. Phone/Fax

Practice location:
  • Phone: 401-455-6346
  • Fax: 401-455-6532
Mailing address:
  • Phone: 917-675-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD13908
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: