Provider Demographics
NPI:1548310287
Name:SHEPPARD, SANDY (OD PC)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SOUTH AVE W
Mailing Address - Street 2:STE. G
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8000
Mailing Address - Country:US
Mailing Address - Phone:406-549-4851
Mailing Address - Fax:406-549-8486
Practice Address - Street 1:700 SOUTH AVE W
Practice Address - Street 2:STE. G
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8000
Practice Address - Country:US
Practice Address - Phone:406-549-4851
Practice Address - Fax:406-549-8486
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT494152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT27640OtherBCBS
MT0482120Medicaid
MT27640OtherBCBS
MT000025110Medicare ID - Type Unspecified
MT000083567Medicare ID - Type Unspecified