MEDICARE: DR. LAQUITA ANN SHEPHERD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	H4698	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8DF664	OTHER	TX	BLUE CROSS

General Provider Information

NPI Number	:	1063483998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAQUITA ANN SHEPHERD MD

Provider Business Mailing Address
First Line	:	1010 N BELT LINE RD STE 105
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75149-1770
Country	:	US
Telephone Number	:	972-686-1234
Fax Number	:	972-686-9000

Provider Business Practice Location Address
First Line	:	1010 N BELT LINE RD STE 105
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75149
Country	:	US
Telephone Number	:	972-686-1234
Fax Number	:	972-686-9000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	05/01/2019

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