Provider Demographics
NPI:1003927856
Name:SHEPARD, DANA LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:LYNN
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RUSSET LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1771
Mailing Address - Country:US
Mailing Address - Phone:860-276-0081
Mailing Address - Fax:
Practice Address - Street 1:3600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3851
Practice Address - Country:US
Practice Address - Phone:203-596-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090002198CT12OtherANTHEM BLUE CROSS
CT090002198CT12OtherANTHEM BLUE CROSS