Provider Demographics
NPI:1548478829
Name:RODDY, SHARON (MD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:
Last Name:RODDY
Suffix:
Gender:F
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:PO BOX 441157
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-1157
Mailing Address - Country:US
Mailing Address - Phone:313-715-4398
Mailing Address - Fax:248-354-0806
Practice Address - Street 1:19111 W 10 MILE RD
Practice Address - Street 2:STE # 164
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2417
Practice Address - Country:US
Practice Address - Phone:248-354-0767
Practice Address - Fax:248-354-0806
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3511909Medicaid
MI3511909Medicaid
OM59620Medicare ID - Type Unspecified