Provider Demographics
NPI:1598803165
Name:SHARRAR, KELLY ANDRE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANDRE
Last Name:SHARRAR
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:PO BOX 2301
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-2301
Mailing Address - Country:US
Mailing Address - Phone:209-682-5228
Mailing Address - Fax:209-682-5227
Practice Address - Street 1:4981 INDIAN PEAK RD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9373
Practice Address - Country:US
Practice Address - Phone:209-742-5977
Practice Address - Fax:209-266-1855
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93376OtherLICENSE
CAA93376OtherLICENSE