Provider Demographics
NPI:1679535942
Name:SHARA, GRETTA (DPM)
Entity type:Individual
Prefix:DR
First Name:GRETTA
Middle Name:
Last Name:SHARA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:ARMADA
Mailing Address - State:MI
Mailing Address - Zip Code:48005-0907
Mailing Address - Country:US
Mailing Address - Phone:586-784-0184
Mailing Address - Fax:586-784-5227
Practice Address - Street 1:23064 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ARMADA
Practice Address - State:MI
Practice Address - Zip Code:48005-4705
Practice Address - Country:US
Practice Address - Phone:586-784-0184
Practice Address - Fax:586-784-5227
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001789213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00301345OtherMEDICARE RAILROAD PIN
MI4855001230OtherBLUE CROSS BLUE SHIELD
MI383335188OtherCOMERCIAL
MIU65279Medicare UPIN
MIP00301345OtherMEDICARE RAILROAD PIN