Provider Demographics
NPI:1982662771
Name:DENNIS D SHEPARD MD INC
Entity Type:Organization
Organization Name:DENNIS D SHEPARD MD INC
Other - Org Name:SHEPARD EYE CENTER MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-614-7005
Mailing Address - Street 1:1418 E MAIN ST
Mailing Address - Street 2:STE 110
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-614-7005
Mailing Address - Fax:805-614-7006
Practice Address - Street 1:1418 E MAIN ST
Practice Address - Street 2:STE 110
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-614-7005
Practice Address - Fax:805-614-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000322261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZH4200ZOtherBLUE SHIELD OF CA
CASUR01010FMedicaid
CAZZZH4200ZOtherBLUE SHIELD OF CA
CASUR01010FMedicaid