Provider Demographics
NPI:1083673479
Name:SHEPPARD, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA MARIE
Middle Name:
Last Name:SHEPPARD
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 1:31 PARK HILL TERRACE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON JUNCTION
Mailing Address - State:NJ
Mailing Address - Zip Code:08550-1944
Mailing Address - Country:US
Mailing Address - Phone:908-284-2300
Mailing Address - Fax:908-442-7432
Practice Address - Street 1:680 BROADWAY STE 111
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1526
Practice Address - Country:US
Practice Address - Phone:973-977-6662
Practice Address - Fax:973-341-1128
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0391232085R0202X
MA2095892085R0202X
FLME753632085R0202X
DECI00070322085R0202X
IDM88202085R0202X
IN01048566A2085R0202X
ME0156792085R0202X
MD000575282085R0202X
MI04744562085R0202X
MT103112085R0202X
NH112562085R0202X
NJMA535192085R0202X
NY179324-12085R0202X
RI104852085R0202X
PAMD044023E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02636560Medicaid
PA001969572Medicaid
NJ7314701Medicaid
OH2863049Medicaid
MD0157457 00Medicaid
MD015745700Medicaid
OK200262470 AMedicaid
IN200933310Medicaid
LA1451789Medicaid
KY7100070710Medicaid
SD7725960Medicaid
MD0157457 00Medicaid
NY02636560Medicaid
PA0000635124Medicare PIN
LA1451789Medicaid
NJ140715WVRMedicare PIN