Healthcare Provider Details

I. General information

NPI: 1578604237
Provider Name (Legal Business Name): SHARON MARLENE WOLLASTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N HOLLYWOOD WAY
BURBANK CA
91505-1826
US

IV. Provider business mailing address

4517 SIMPSON AVE
STUDIO CITY CA
91607-4134
US

V. Phone/Fax

Practice location:
  • Phone: 818-841-9990
  • Fax: 818-972-9067
Mailing address:
  • Phone: 818-985-7334
  • Fax: 818-972-9067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA064194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: