Provider Demographics
NPI:1184630279
Name:SHEPPARD, BENJAMIN W (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:W
Last Name:SHEPPARD
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 1:167 SOUTH CONWELL STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2791
Mailing Address - Country:US
Mailing Address - Phone:307-234-6988
Mailing Address - Fax:307-472-2854
Practice Address - Street 1:167 SOUTH CONWELL STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2791
Practice Address - Country:US
Practice Address - Phone:307-234-6988
Practice Address - Fax:307-472-2854
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3091A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1134272917Medicaid
WYW4371034CMedicare PIN
A73185Medicare UPIN