Provider Demographics
NPI:1396827341
Name:SHARPE, SUSIE K (MD)
Entity type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:K
Last Name:SHARPE
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1600 W PHELPS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-4273
Practice Address - Country:US
Practice Address - Phone:417-575-9603
Practice Address - Fax:417-575-9577
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203852603Medicaid
MOF58151Medicare UPIN
MO074013230Medicare PIN
MO121013268Medicare PIN