Provider Demographics
NPI:1073704268
Name:SHEPHERD, LONI LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LONI
Middle Name:LYNN
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:208 OAK DR S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5790
Mailing Address - Country:US
Mailing Address - Phone:979-285-2900
Mailing Address - Fax:979-285-2904
Practice Address - Street 1:208 OAK DR S
Practice Address - Street 2:SUITE 400
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5790
Practice Address - Country:US
Practice Address - Phone:979-285-2900
Practice Address - Fax:979-285-2904
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0029096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214871001Medicaid
4644840750OtherMYUTMB 4644840750