Healthcare Provider Details

I. General information

NPI: 1962798066
Provider Name (Legal Business Name): SHANE JAMES SHEPARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N BRENT ST
VENTURA CA
93003-2810
US

IV. Provider business mailing address

124 N BRENT ST
VENTURA CA
93003-2810
US

V. Phone/Fax

Practice location:
  • Phone: 805-641-9880
  • Fax: 805-641-9890
Mailing address:
  • Phone: 805-641-9880
  • Fax: 805-641-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA130296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: