Provider Demographics
NPI:1043290224
Name:SHEPPARD, SHELLY YVON (OD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:YVON
Last Name:SHEPPARD
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 1:1801 SANTA CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2631
Mailing Address - Country:US
Mailing Address - Phone:510-521-2015
Mailing Address - Fax:510-521-2123
Practice Address - Street 1:1801 SANTA CLARA AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2631
Practice Address - Country:US
Practice Address - Phone:510-521-2015
Practice Address - Fax:510-521-2123
Is Sole Proprietor?:No
Enumeration Date:2006-01-22
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11090T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU75964Medicare UPIN
CASD0110900Medicare ID - Type Unspecified