Provider Demographics
NPI:1770772717
Name:SHARMA, MOHAN L (MD)
Entity type:Individual
Prefix:
First Name:MOHAN
Middle Name:L
Last Name:SHARMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 E RICH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-4357
Mailing Address - Country:US
Mailing Address - Phone:386-736-1444
Mailing Address - Fax:386-736-9337
Practice Address - Street 1:231 E RICH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-4357
Practice Address - Country:US
Practice Address - Phone:386-736-1444
Practice Address - Fax:386-736-9337
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378534300Medicaid
FL27717OtherBCBS
FL5647614OtherAETNA
FLF81784Medicare UPIN
FL27717OtherBCBS