Provider Demographics
NPI:1083790562
Name:SHEPKO, STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:SHEPKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 PARKVILLE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1373
Mailing Address - Country:US
Mailing Address - Phone:718-421-1200
Mailing Address - Fax:718-421-6573
Practice Address - Street 1:229 PARKVILLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1373
Practice Address - Country:US
Practice Address - Phone:718-421-1200
Practice Address - Fax:718-421-6573
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092719-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0078299OtherGHI
NY01010484Medicaid
NY01010484Medicaid
NY0078299OtherGHI