Healthcare Provider Details

I. General information

NPI: 1508855198
Provider Name (Legal Business Name): CLINTON HARRY SHARP III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 GAUSE BLVD SUITE 380
SLIDELL LA
70458-2951
US

IV. Provider business mailing address

1051 GAUSE BLVD SUITE 380
SLIDELL LA
70458-2951
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-8191
  • Fax: 985-641-9812
Mailing address:
  • Phone: 985-641-8191
  • Fax: 985-641-9812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16693
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11192
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: