Provider Demographics
NPI:1184182081
Name:SHEPHERD, JOSEPH (MS, RD/LD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:MS, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10728 HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-8594
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:405-269-3154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-10
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2380133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered