Provider Demographics
NPI:1245376300
Name:SMITH, SHARON ANNE (M D)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MILWAUKEE AVE
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1230
Mailing Address - Country:US
Mailing Address - Phone:262-763-9128
Mailing Address - Fax:262-763-9120
Practice Address - Street 1:425 MILWAUKEE AVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1230
Practice Address - Country:US
Practice Address - Phone:262-763-9128
Practice Address - Fax:262-763-9120
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30289800Medicaid
WI30289800Medicaid