Healthcare Provider Details

I. General information

NPI: 1689741563
Provider Name (Legal Business Name): JEANNE PRUSA SHEPHERD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-3910
  • Fax:
Mailing address:
  • Phone: 909-427-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberG60529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: