Provider Demographics
NPI:1093918013
Name:SHEPHERD, PAUL (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2726 GRIFFIN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2362
Mailing Address - Country:US
Mailing Address - Phone:360-825-3000
Mailing Address - Fax:360-825-8408
Practice Address - Street 1:2726 GRIFFIN AVE STE B
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2362
Practice Address - Country:US
Practice Address - Phone:360-825-3000
Practice Address - Fax:360-825-8408
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA026101-OD00001619152W00000X
WA1816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASH2147OtherREGENCE
WA2016699Medicaid
WAG000104900Medicare PIN
WASH2147OtherREGENCE
G8886344Medicare PIN