Provider Demographics
NPI:1801967096
Name:SHEPPERD, MILTON WIRTZ (DO)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:WIRTZ
Last Name:SHEPPERD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1930
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-2680
Mailing Address - Country:US
Mailing Address - Phone:830-693-1792
Mailing Address - Fax:830-693-1685
Practice Address - Street 1:113 BROADMOOR ST
Practice Address - Street 2:
Practice Address - City:MEADOWLAKES
Practice Address - State:TX
Practice Address - Zip Code:78654-6601
Practice Address - Country:US
Practice Address - Phone:830-693-1792
Practice Address - Fax:830-693-1685
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6722207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113654105Medicaid
TX0068AAOtherBLUE CROSS BLUE SHIELD
TX110141641OtherRAILROAD MEDICARE
TX113654104Medicaid
TXF88206Medicare UPIN
TX110141641OtherRAILROAD MEDICARE
TX8F1035Medicare ID - Type Unspecified