Provider Demographics
NPI:1184810442
Name:SANDY SHEPPARD OD PC
Entity type:Organization
Organization Name:SANDY SHEPPARD OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-549-4851
Mailing Address - Street 1:700 SOUTH AVE W
Mailing Address - Street 2:STE. G
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8000
Mailing Address - Country:US
Mailing Address - Phone:406-549-4851
Mailing Address - Fax:406-549-8486
Practice Address - Street 1:700 SOUTH AVE W
Practice Address - Street 2:STE. G
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8000
Practice Address - Country:US
Practice Address - Phone:406-549-4851
Practice Address - Fax:406-549-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT0494152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4652470001Medicare NSC
MT000025110Medicare PIN
MT000083567Medicare PIN