Provider Demographics
NPI:1104880079
Name:SHARP, JACK KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:KEVIN
Last Name:SHARP
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-8888
Mailing Address - Fax:910-662-8909
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-662-8888
Practice Address - Fax:910-662-8909
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216985-12080P0214X
NY2169852080P0214X
NC2012-019112080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00021037301OtherUNIVERA
PA001819708001Medicaid
000525957001OtherBC/BS
4410946OtherIHA
040426001868OtherFIDELIS
NY02062031Medicaid
PA001819708001Medicaid
CC6679Medicare PIN
000525957001OtherBC/BS