Provider Demographics
NPI:1962798066
Name:SHEPARD, SHANE JAMES (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:JAMES
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N BRENT ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2810
Mailing Address - Country:US
Mailing Address - Phone:805-641-9880
Mailing Address - Fax:805-641-9890
Practice Address - Street 1:124 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2810
Practice Address - Country:US
Practice Address - Phone:805-641-9880
Practice Address - Fax:805-641-9890
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA130296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program