Provider Demographics
NPI:1174529986
Name:SHEPHERD, DAVID JAMES JR (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:SHEPHERD
Suffix:JR
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:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:580-237-0322
Mailing Address - Fax:
Practice Address - Street 1:721 W BROADWAY AVE STE D
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3800
Practice Address - Country:US
Practice Address - Phone:580-237-0322
Practice Address - Fax:580-233-0402
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00066745OtherRAILROAD MEDICARE PTAN
730776935005OtherBLUE CROSS ID
OK100123330AMedicaid
OK100123330AMedicaid
AS 1080302OtherDEA
D35270Medicare UPIN