Provider Demographics
NPI:1760499867
Name:SHEPHERD, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:SHEPHERD
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:PO BOX 4087
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-4087
Mailing Address - Country:US
Mailing Address - Phone:662-844-4911
Mailing Address - Fax:662-844-8275
Practice Address - Street 1:670 CROSSOVER RD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4944
Practice Address - Country:US
Practice Address - Phone:662-844-8414
Practice Address - Fax:662-844-7275
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14824207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCHO754OtherRAILROAD MEDICARE GROUP
MS460001322OtherRAILROAD MEDICARE
MS00116650Medicaid
MSD93216Medicare UPIN
MS460000004Medicare PIN