Healthcare Provider Details

I. General information

NPI: 1265420012
Provider Name (Legal Business Name): MARK J SHEPARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7442 FRANK AVE NW
NORTH CANTON OH
44720-7022
US

IV. Provider business mailing address

7442 FRANK AVE NW
NORTH CANTON OH
44720-7022
US

V. Phone/Fax

Practice location:
  • Phone: 330-305-0838
  • Fax: 330-305-2514
Mailing address:
  • Phone: 330-455-5367
  • Fax: 330-455-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number35068710
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number34068710
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: