Provider Demographics
NPI:1568666170
Name:DIAMOND-MYRSTEN, SHARON L (MD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:L
Last Name:DIAMOND-MYRSTEN
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-924-5348
Practice Address - Fax:434-924-8335
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1568666170Medicaid
VA0101241776OtherSTATE LICENSE
VA014458M68Medicare PIN