Healthcare Provider Details

I. General information

NPI: 1679535942
Provider Name (Legal Business Name): GRETTA SHARA DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23064 E MAIN ST
ARMADA MI
48005-4705
US

IV. Provider business mailing address

PO BOX 907
ARMADA MI
48005-0907
US

V. Phone/Fax

Practice location:
  • Phone: 586-784-0184
  • Fax: 586-784-5227
Mailing address:
  • Phone: 586-784-0184
  • Fax: 586-784-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001789
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001789
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: