Healthcare Provider Details

I. General information

NPI: 1235271420
Provider Name (Legal Business Name): DIABETES & GERIATRICS SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 S WILLOW AVE SUITE A
COOKEVILLE TN
38501-3191
US

IV. Provider business mailing address

146 S WILLOW AVE SUITE A
COOKEVILLE TN
38501-3191
US

V. Phone/Fax

Practice location:
  • Phone: 931-646-0880
  • Fax: 931-646-0884
Mailing address:
  • Phone: 931-646-0880
  • Fax: 931-646-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number40259
License Number StateTN

VIII. Authorized Official

Name: PARDEEP KUMAR SHARMA
Title or Position: OWNER
Credential: M.D.
Phone: 931-646-0880