Basic Information
| Provider Information | |||||||||
| NPI: | 1437202116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARETTS | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550340 | ||||||||
| FaxNumber: | 8563550330 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 BURRS RD STE C | ||||||||
| Address2: | |||||||||
| City: | WESTAMPTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080605517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098717500 | ||||||||
| FaxNumber: | 6094445657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD030059E | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085D0003X | MD030059E | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085D0003X | 25MA04242500 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2084N0400X | 25MA04242500 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2462303 | 05 | NJ | MEDICAID |