Provider Demographics
NPI:1174986756
Name:SHEPHERD, SHANTA (MD,)
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 E NEWTON ST
Mailing Address - Street 2:C515
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 WOODLAND ST STE 23
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2368
Practice Address - Country:US
Practice Address - Phone:860-522-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT68747208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program