Provider Demographics
NPI:1073321352
Name:SHEPHERD, SAMUEL SR
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SHEPHERD
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-7801
Mailing Address - Country:US
Mailing Address - Phone:614-516-3972
Mailing Address - Fax:
Practice Address - Street 1:1033 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-7801
Practice Address - Country:US
Practice Address - Phone:614-516-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRUALSKLK172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver