Provider Demographics
NPI:1639204357
Name:GREENE, SHEPARD JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHEPARD
Middle Name:JAY
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 HOSPITAL LN
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4918
Mailing Address - Country:US
Mailing Address - Phone:530-251-8108
Mailing Address - Fax:
Practice Address - Street 1:555 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4918
Practice Address - Country:US
Practice Address - Phone:530-251-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA519102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry