Provider Demographics
NPI:1184816092
Name:DAVID M. SHEPHERD MD PC
Entity Type:Organization
Organization Name:DAVID M. SHEPHERD MD PC
Other - Org Name:STYLE-EYES OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-347-8030
Mailing Address - Street 1:41935 W 12 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3111
Mailing Address - Country:US
Mailing Address - Phone:248-347-8030
Mailing Address - Fax:248-305-6694
Practice Address - Street 1:41935 W 12 MILE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3111
Practice Address - Country:US
Practice Address - Phone:248-347-8030
Practice Address - Fax:248-305-6694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI32402207W00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDE3726OtherMEDICARE RAILROAD
MI27670Medicare PIN
MIE 25765Medicare UPIN