Provider Demographics
NPI:1962481713
Name:SHEPHERD, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 11023
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2023
Mailing Address - Country:US
Mailing Address - Phone:423-778-3274
Mailing Address - Fax:423-778-2255
Practice Address - Street 1:1100 EAST THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2241
Practice Address - Country:US
Practice Address - Phone:423-778-8837
Practice Address - Fax:423-778-9301
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG459940207Q00000X
TN48225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770560203 0005OtherCIGNA
CAZZZ43971ZOtherBLUE SHIELD
CA770560203OtherBLUE CROSS
CA00G459940Medicaid
CAZZZ43971ZOtherBLUE SHIELD
CA00G459940Medicaid