Provider Demographics
NPI:1336170653
Name:SHEPHERD, LARRY MASON (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:MASON
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 1:801 EASTWIND DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3303
Mailing Address - Country:US
Mailing Address - Phone:614-882-9460
Mailing Address - Fax:614-882-9802
Practice Address - Street 1:801 EASTWIND DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-3303
Practice Address - Country:US
Practice Address - Phone:614-882-9460
Practice Address - Fax:614-882-9802
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.051445208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0576765Medicaid