Provider Demographics
NPI:1528440773
Name:AVERY, SHARIFA RUQAYAH (MD)
Entity type:Individual
Prefix:
First Name:SHARIFA
Middle Name:RUQAYAH
Last Name:AVERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 STEVE REYNOLDS BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4506
Mailing Address - Country:US
Mailing Address - Phone:347-200-5279
Mailing Address - Fax:
Practice Address - Street 1:222 STATION PLZ N
Practice Address - Street 2:SUITE 509
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3800
Practice Address - Country:US
Practice Address - Phone:516-663-2781
Practice Address - Fax:516-663-8796
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA81025207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program