Provider Demographics
NPI:1790896769
Name:SHARIFI, SUSAN CORRINE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CORRINE
Last Name:SHARIFI
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3125
Mailing Address - Fax:812-242-3446
Practice Address - Street 1:1739 N 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4002
Practice Address - Country:US
Practice Address - Phone:812-242-3125
Practice Address - Fax:812-242-3446
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043795A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200036030AMedicaid
INP00834680OtherRAILROAD MEDICARE
000000089650OtherANTHEM
IN200036030Medicaid
IN200036030SMedicaid
130013869OtherRAILROAD MCARE PALAMETTO
IN187310DMedicare PIN
000000089650OtherANTHEM
IN200036030AMedicaid
130013869OtherRAILROAD MCARE PALAMETTO
IN607850AMedicare PIN
IN265130A7Medicare PIN
IN859920VMedicare PIN