Provider Demographics
NPI:1023269677
Name:DANA L SHEPARD OD & ASSOCIATES INC
Entity type:Organization
Organization Name:DANA L SHEPARD OD & ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-596-0406
Mailing Address - Street 1:22 RUSSET LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1771
Mailing Address - Country:US
Mailing Address - Phone:203-596-0406
Mailing Address - Fax:
Practice Address - Street 1:3600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3851
Practice Address - Country:US
Practice Address - Phone:203-596-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty