Provider Demographics
NPI:1669412235
Name:SHARAF, WAYNE RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:RUSSELL
Last Name:SHARAF
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 1:3971 PREEMPTION RD
Mailing Address - Street 2:
Mailing Address - City:WATKINS GLEN
Mailing Address - State:NY
Mailing Address - Zip Code:14891-9766
Mailing Address - Country:US
Mailing Address - Phone:607-535-7983
Mailing Address - Fax:
Practice Address - Street 1:7571 STATE ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-9504
Practice Address - Country:US
Practice Address - Phone:607-776-8500
Practice Address - Fax:607-776-8837
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E94384Medicare UPIN
NYRA5829Medicare ID - Type Unspecified