Provider Demographics
NPI:1063452159
Name:SHEPPARD, GERON F (MD)
Entity Type:Individual
Prefix:DR
First Name:GERON
Middle Name:F
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GERON
Other - Middle Name:
Other - Last Name:SHEPPARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 20130
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92516-0130
Mailing Address - Country:US
Mailing Address - Phone:323-908-7615
Mailing Address - Fax:323-924-5971
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:A108
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-7171
Practice Address - Fax:909-558-0121
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG064395207P00000X
MO2011001502207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MO500410084Medicare PIN
00G64395Medicare PIN
MOPENDINGMedicaid