Provider Demographics
NPI:1144210352
Name:SHEPHERD, MARY ELIZABETH (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MD,PHD
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 171179
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-0041
Mailing Address - Country:US
Mailing Address - Phone:512-526-1776
Mailing Address - Fax:512-298-1277
Practice Address - Street 1:12545 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6524
Practice Address - Country:US
Practice Address - Phone:512-526-1776
Practice Address - Fax:512-298-1277
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6599207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B8802OtherBLUE CROSS BLUE SHIELD
TX105402503Medicaid
TX8L3519Medicare PIN