Healthcare Provider Details

I. General information

NPI: 1174986756
Provider Name (Legal Business Name): SHANTA SHEPHERD M.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 HEBRON AVE STE 10
GLASTONBURY CT
06033-5016
US

IV. Provider business mailing address

730 HEBRON AVE STE 10
GLASTONBURY CT
06033-5016
US

V. Phone/Fax

Practice location:
  • Phone: 860-266-5550
  • Fax: 860-266-5511
Mailing address:
  • Phone: 860-266-5550
  • Fax: 860-266-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number68747
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD496871
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: