Provider Demographics
NPI:1053495812
Name:BEDFORD, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BEDFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 JORDAN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8343
Practice Address - Country:US
Practice Address - Phone:518-274-9126
Practice Address - Fax:518-274-9487
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150106207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01279294Medicaid
NYB01515Medicare UPIN
NY01279294Medicaid