Healthcare Provider Details

I. General information

NPI: 1376559880
Provider Name (Legal Business Name): MARK DEVIN SHEPHERD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 CROSSOVER RD
TUPELO MS
38801-4944
US

IV. Provider business mailing address

PO BOX 4087
TUPELO MS
38803-4087
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-8414
  • Fax: 662-844-8275
Mailing address:
  • Phone: 662-844-8414
  • Fax: 662-844-8275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: DR. MARK D SHEPHERD
Title or Position: DIRECTOR
Credential: M.D.
Phone: 662-844-8414