Provider Demographics
NPI:1154881993
Name:SHARP, KRISTIN (DO)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:SHARP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1464
Mailing Address - Country:US
Mailing Address - Phone:574-335-6504
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 406
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:743-335-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN390200000X
IN02006676A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300026890Medicaid