Provider Demographics
NPI:1164535910
Name:SHEPHERDSON, JOHN DUDLEY (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DUDLEY
Last Name:SHEPHERDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2001
Mailing Address - Country:US
Mailing Address - Phone:309-266-9711
Mailing Address - Fax:309-266-6322
Practice Address - Street 1:107 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2001
Practice Address - Country:US
Practice Address - Phone:309-266-9711
Practice Address - Fax:309-266-6322
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL058746OtherHEALTH ALLIANCE
IL227840OtherHEALTH LINK
IL227840OtherHEALTH LINK
ILE25739Medicare UPIN