Provider Demographics
NPI:1689755795
Name:SHEPPERD, JOEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:ROBERT
Last Name:SHEPPERD
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 1:400 E 22ND ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6104
Mailing Address - Country:US
Mailing Address - Phone:630-792-9311
Mailing Address - Fax:630-792-9316
Practice Address - Street 1:400 E 22ND ST
Practice Address - Street 2:SUITE F
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6104
Practice Address - Country:US
Practice Address - Phone:630-792-9311
Practice Address - Fax:630-792-9316
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043409A208D00000X
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D12871Medicare UPIN
ILL55846Medicare ID - Type Unspecified