Healthcare Provider Details

I. General information

NPI: 1114048329
Provider Name (Legal Business Name): JONATHAN PAUL SHEPHERD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-8036
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8036
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4100
  • Fax: 860-679-1064
Mailing address:
  • Phone: 860-679-4100
  • Fax: 860-679-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number269626
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number55313
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: