Provider Demographics
NPI:1417919432
Name:ANDERSON, SHARON R (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0130
Mailing Address - Country:US
Mailing Address - Phone:573-341-2971
Mailing Address - Fax:573-341-8174
Practice Address - Street 1:1210 HOMELIFE PLZ
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2512
Practice Address - Country:US
Practice Address - Phone:573-341-2971
Practice Address - Fax:573-341-8174
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000780213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO308858919Medicaid
MO308858919Medicaid
MO000021503Medicare ID - Type UnspecifiedDPM