Provider Demographics
NPI:1275630816
Name:CHARLES SHEPTIN, MD, INC.
Entity Type:Organization
Organization Name:CHARLES SHEPTIN, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-464-8293
Mailing Address - Street 1:1792 KIRKMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-1235
Mailing Address - Country:US
Mailing Address - Phone:408-464-8293
Mailing Address - Fax:
Practice Address - Street 1:1792 KIRKMONT DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-1235
Practice Address - Country:US
Practice Address - Phone:408-464-8293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12008261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G12008Medicaid
A38515Medicare UPIN
CA00G12008Medicaid