=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285802041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERT E. SHARP, D.P.M., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2008
-----------------------------------------------------
Last Update Date | 01/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 N 4TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-6616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-757-2300
-----------------------------------------------------
Fax | 903-758-0279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 613 N 4TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-6616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-757-2300
-----------------------------------------------------
Fax | 903-758-0279
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BERT EAGLE SHARP
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 903-757-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 1032
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------