Provider Demographics
NPI:1568752863
Name:SHEPARD, BENJAMIN ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ANDREW
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W MOBILE PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-7861
Mailing Address - Country:US
Mailing Address - Phone:423-943-2643
Mailing Address - Fax:
Practice Address - Street 1:717 S HOUSTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-382-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200474330AMedicaid