Provider Demographics
NPI:1164402012
Name:ULSTAD, SHARLA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SHARLA
Middle Name:MARIE
Last Name:ULSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MIDTOWNE STREET NE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-588-1200
Mailing Address - Fax:616-391-1250
Practice Address - Street 1:555 MIDTOWNE STREET NE
Practice Address - Street 2:SUITE 400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-588-1200
Practice Address - Fax:616-588-1250
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080110207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104836177Medicaid
MIP53200032Medicare PIN
MI104836177Medicaid