Provider Demographics
NPI:1124409172
Name:SHARMOUK, SHADY
Entity Type:Individual
Prefix:
First Name:SHADY
Middle Name:
Last Name:SHARMOUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 LEMAR PARK DR
Mailing Address - Street 2:APT B
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4439
Mailing Address - Country:US
Mailing Address - Phone:626-931-0696
Mailing Address - Fax:
Practice Address - Street 1:623 LEMAR PARK DR
Practice Address - Street 2:APT B
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4439
Practice Address - Country:US
Practice Address - Phone:626-931-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)