Healthcare Provider Details

I. General information

NPI: 1780078477
Provider Name (Legal Business Name): KENNETH B SHEPHARD MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 N KENDALL DR STE 102
MIAMI FL
33176-2206
US

IV. Provider business mailing address

8700 N KENDALL DR STE 102
MIAMI FL
33176-2206
US

V. Phone/Fax

Practice location:
  • Phone: 305-273-1919
  • Fax: 305-273-1929
Mailing address:
  • Phone: 305-273-1919
  • Fax: 305-273-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANN THEISEN
Title or Position: ACCT
Credential:
Phone: 786-475-3971