Provider Demographics
NPI:1033170154
Name:SHEPHERD, WILLARD N (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:N
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 JONES RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8207
Mailing Address - Country:US
Mailing Address - Phone:252-443-1006
Mailing Address - Fax:252-937-8366
Practice Address - Street 1:450 JONES RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8207
Practice Address - Country:US
Practice Address - Phone:252-443-1006
Practice Address - Fax:252-937-8366
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909825Medicaid
NC09825OtherBCBS
NC246483EMedicare ID - Type Unspecified
NC8909825Medicaid