Provider Demographics
NPI:1013434398
Name:SHEPARD, SIMEON
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13238 ROYAL GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-5724
Mailing Address - Country:US
Mailing Address - Phone:386-566-1949
Mailing Address - Fax:
Practice Address - Street 1:13238 ROYAL GEORGE AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556
Practice Address - Country:US
Practice Address - Phone:386-566-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL119725246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant