Provider Demographics
NPI:1205852845
Name:SHARON, IDAN (MD)
Entity Type:Individual
Prefix:
First Name:IDAN
Middle Name:
Last Name:SHARON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 BOND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-4812
Mailing Address - Country:US
Mailing Address - Phone:718-680-8105
Mailing Address - Fax:718-680-6556
Practice Address - Street 1:6917 SHORE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-1000
Practice Address - Country:US
Practice Address - Phone:718-680-8105
Practice Address - Fax:718-680-6556
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02085821Medicaid
NY02085821Medicaid
NYG07045Medicare UPIN