Provider Demographics
NPI:1326001868
Name:BRUCE D SHEPHARD MD PA
Entity Type:Organization
Organization Name:BRUCE D SHEPHARD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHEPHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-928-5276
Mailing Address - Street 1:13014 N DALE MABRY HWY
Mailing Address - Street 2:#208
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2808
Mailing Address - Country:US
Mailing Address - Phone:813-928-5276
Mailing Address - Fax:
Practice Address - Street 1:13014 N DALE MABRY HWY
Practice Address - Street 2:#208
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2808
Practice Address - Country:US
Practice Address - Phone:813-928-5276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24560207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374753100Medicaid
FL374753100Medicaid
FLDZ506AMedicare PIN