Healthcare Provider Details

I. General information

NPI: 1649327594
Provider Name (Legal Business Name): BRADLEY DAVID SHEPHERD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SUMMIT BLVD STE 200
BROOKHAVEN GA
30319-6410
US

IV. Provider business mailing address

1001
ATHENS GA
30601-3806
US

V. Phone/Fax

Practice location:
  • Phone: 770-989-1668
  • Fax: 678-388-1759
Mailing address:
  • Phone: 706-548-0008
  • Fax: 706-369-9673

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40842
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number40842
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number066420
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: