Provider Demographics
NPI:1780836452
Name:TIMOTHY S. SHEPHERD MD PA
Entity Type:Organization
Organization Name:TIMOTHY S. SHEPHERD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-420-8777
Mailing Address - Street 1:314 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3866
Mailing Address - Country:US
Mailing Address - Phone:972-420-8777
Mailing Address - Fax:
Practice Address - Street 1:314 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3866
Practice Address - Country:US
Practice Address - Phone:972-420-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00DQ67OtherBLUE CROSS
TXDP4526OtherRAILROAD MEDICARE
TX202610601Medicaid
TXB26392OtherCOMMERCIAL
TX00Z699Medicare PIN