Provider Demographics
NPI:1083605638
Name:SHEPARD, JOANNE OMALLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:OMALLEY
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-4256
Mailing Address - Fax:617-724-0046
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:FND 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-4256
Practice Address - Fax:617-724-0046
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA437002085R0202X
NY2117082085R0202X
ME0144032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0145904Medicaid
MA724090OtherTUFTS HEALTH PLAN
MAC05306OtherBCBS MA
MA0145904Medicaid
MAC05306OtherBCBS MA