Provider Demographics
NPI:1780641688
Name:SHEPARD, WARREN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:DAVID
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:110 OLSEN BLVD NE
Practice Address - Street 2:
Practice Address - City:COKATO
Practice Address - State:MN
Practice Address - Zip Code:55321-4359
Practice Address - Country:US
Practice Address - Phone:320-286-2123
Practice Address - Fax:320-286-6194
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110015026Medicare PIN