Provider Demographics
NPI:1417156274
Name:SHAW-BERROCAL, SHARONDA A (DO)
Entity Type:Individual
Prefix:
First Name:SHARONDA
Middle Name:A
Last Name:SHAW-BERROCAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHARONDA
Other - Middle Name:A
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:31 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3556
Mailing Address - Country:US
Mailing Address - Phone:708-596-5177
Mailing Address - Fax:708-589-2084
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3556
Practice Address - Country:US
Practice Address - Phone:630-697-2601
Practice Address - Fax:708-589-2084
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-126062207P00000X
IN02003385A207Q00000X
FLOS15645207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400054921Medicare PIN
IN048580O6Medicare PIN