Provider Demographics
NPI:1811915762
Name:IRVINE, SHARON M (DO)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:M
Last Name:IRVINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3400
Mailing Address - Country:US
Mailing Address - Phone:817-453-5912
Mailing Address - Fax:817-453-2988
Practice Address - Street 1:1720 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3400
Practice Address - Country:US
Practice Address - Phone:817-453-5912
Practice Address - Fax:817-453-2988
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0972OtherPTAN
TX044106502Medicaid
TX870749737OtherTAX ID
TX870749737OtherTAX ID
TX044106502Medicaid