Basic Information
| Provider Information | |||||||||
| NPI: | 1811985070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CAMP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 PLAZA CT N STE 1A | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800262832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036653036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 W SOUTH BOULDER RD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800261389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036659310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 23339 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01233394 | 05 | CO | MEDICAID | AS2120967 | 01 | DEA | OTHER |