Healthcare Provider Details

I. General information

NPI: 1548243926
Provider Name (Legal Business Name): DEREK J SHARVELLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3746 ROME DR
LAFAYETTE IN
47905-4489
US

IV. Provider business mailing address

PO BOX 472
MUNCIE IN
47308-0472
US

V. Phone/Fax

Practice location:
  • Phone: 765-449-3937
  • Fax: 765-449-5856
Mailing address:
  • Phone: 765-286-8888
  • Fax: 765-747-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01020187
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: