Provider Demographics
NPI:1093926263
Name:SHEPHERD, CLIFTON W (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:W
Last Name:SHEPHERD
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:PO BOX 53668
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3668
Mailing Address - Country:US
Mailing Address - Phone:337-280-9200
Mailing Address - Fax:
Practice Address - Street 1:8660 FERN AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5649
Practice Address - Country:US
Practice Address - Phone:337-280-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014211174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1186155Medicaid
LA1186155Medicaid
LA54085F699Medicare PIN