Provider Demographics
NPI:1063499184
Name:SHEPHERD, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3905
Mailing Address - Country:US
Mailing Address - Phone:515-574-6890
Mailing Address - Fax:515-574-6458
Practice Address - Street 1:2015 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3000
Practice Address - Country:US
Practice Address - Phone:712-732-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00881OtherBC/BS ER LOCATION
IA01644OtherWELLMARK BCBS CLINIC LOCA
IA1469452Medicaid
IAI14710OtherCOVENTRY HEALTH CARE
IA0121965OtherUNITED HEALTH CARE
IA246974OtherMIDLANDS CHOICE
IA4878OtherAVERA HEALTH PLAN
IN0469452Medicaid
IA45838OtherSIOUX VALLEY HEALTH PLAN
IA42603840551041OtherWPS TRICARE
IA01644OtherFIRST ADMINISTRATORS
IA426038405OtherCIGNA
IA9233000OtherDAKOTACARE
IA0121965OtherMEDICA
IA703361045139OtherPREFERRED ONE
IAI14710OtherCOVENTRY HEALTH CARE
IA426038405OtherCIGNA
IAP00470135Medicare PIN