Provider Demographics
NPI:1366401580
Name:SHARP, SUSAN M
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SHARP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77790
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0126
Mailing Address - Country:US
Mailing Address - Phone:951-278-5590
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:17400 IRVINE BLVD M
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-542-5988
Practice Address - Fax:951-272-9924
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG64148Medicare UPIN