MEDICARE: JACK P. SHEPHERD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	200201174	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952353781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK P. SHEPHERD MD

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 BILLINGSLEY RD STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-5020
Country	:	US
Telephone Number	:	704-316-2333
Fax Number	:	704-316-2334

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	08/19/2021

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