Provider Demographics
NPI:1841495231
Name:V. JERRY SHEPHERD, M.D.
Entity type:Organization
Organization Name:V. JERRY SHEPHERD, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLAIMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-376-0649
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-0966
Mailing Address - Country:US
Mailing Address - Phone:405-376-0649
Mailing Address - Fax:
Practice Address - Street 1:3383 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065-3634
Practice Address - Country:US
Practice Address - Phone:405-376-0649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7344156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE11032Medicare UPIN