Provider Demographics
NPI:1063725273
Name:SHARP, SHASTINE M (MD)
Entity type:Individual
Prefix:
First Name:SHASTINE
Middle Name:M
Last Name:SHARP
Suffix:
Gender:
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:825 BARRET AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1743
Practice Address - Country:US
Practice Address - Phone:931-245-8600
Practice Address - Fax:931-245-8660
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50146207Q00000X
KY47825207Q00000X
PAMT197438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1532928Medicaid
KY7100650020Medicaid