Provider Demographics
NPI:1780078477
Name:KENNETH B SHEPHARD MD PA
Entity type:Organization
Organization Name:KENNETH B SHEPHARD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-475-3971
Mailing Address - Street 1:8700 N KENDALL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-2206
Mailing Address - Country:US
Mailing Address - Phone:305-273-1919
Mailing Address - Fax:305-273-1929
Practice Address - Street 1:8700 N KENDALL DR STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2206
Practice Address - Country:US
Practice Address - Phone:305-273-1919
Practice Address - Fax:305-273-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG19282Medicare UPIN