Basic Information
| Provider Information | |||||||||
| NPI: | 1013368752 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHARPCARE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8695 SPECTRUM CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584993025 | ||||||||
| FaxNumber: | 8584994738 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 PROSPECT PL STE 340B | ||||||||
| Address2: | |||||||||
| City: | CORONADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921181991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195224000 | ||||||||
| FaxNumber: | 6194350150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2016 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8584994003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARP HEALTHCARE | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 95-1193 | 01 | MEDICARE | OTHER |