Provider Demographics
NPI:1992757744
Name:SHEPHERDSON, GARY L (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:SHEPHERDSON
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 1:1320 WISCONSIN AVE
Mailing Address - Street 2:MCW & ALL SAINTS HEALTH CARE SYSTEM
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MCW & ALL SAINTS HEALTH CARE SYSTEM
Practice Address - Street 2:1320 WISCONSIN AVE.
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403
Practice Address - Country:US
Practice Address - Phone:262-638-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30251600Medicaid
B56567Medicare UPIN
WI30251600Medicaid