Basic Information
| Provider Information | |||||||||
| NPI: | 1912908393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTIE | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 SAYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603582780 | ||||||||
| FaxNumber: | 8603582781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | 038326 | CT | Y | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 401367 | 01 | HARVARD PILGRIM | OTHER | P2064320 | 01 | OXFORD | OTHER | 0V7245 | 01 | HEALTH NET | OTHER | 150894 | 01 | CONNECTICARE | OTHER | 2340445 | 01 | AETNA | OTHER | 010038326CT02 | 01 | CT | BCBS | OTHER | 070014961 | 01 | RAILROAD MEDICARE | OTHER |