Provider Demographics
NPI:1467421826
Name:SHEPHARD, BRUCE DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DENNIS
Last Name:SHEPHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:DENNIS
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24560207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374753100Medicaid
D85495Medicare UPIN
FL374753100Medicaid