Provider Demographics
NPI:1447203740
Name:SHEPHERD, GLYNETTA (OD)
Entity Type:Individual
Prefix:DR
First Name:GLYNETTA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:GLYNETTA
Other - Middle Name:SHEPHERD
Other - Last Name:VOGT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:7 STAUNTON CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-9271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 OVER MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2855
Practice Address - Country:US
Practice Address - Phone:423-543-8230
Practice Address - Fax:423-543-8305
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU97101Medicare UPIN
TN3945995Medicare ID - Type Unspecified