Healthcare Provider Details

I. General information

NPI: 1780677146
Provider Name (Legal Business Name): LAURENCE M. SHARP DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W HARVARD AVE SUITE 426
ROSEBURG OR
97471-2752
US

IV. Provider business mailing address

PO BOX 2346
ROSEBURG OR
97470-0462
US

V. Phone/Fax

Practice location:
  • Phone: 541-459-1611
  • Fax: 541-459-5741
Mailing address:
  • Phone: 541-459-1611
  • Fax: 541-459-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO15192
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: