Provider Demographics
NPI:1649327594
Name:SHEPHERD, BRADLEY DAVID (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DAVID
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-3806
Mailing Address - Country:US
Mailing Address - Phone:706-548-0008
Mailing Address - Fax:706-369-9673
Practice Address - Street 1:1001 SUMMIT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-6410
Practice Address - Country:US
Practice Address - Phone:770-989-1668
Practice Address - Fax:678-388-1759
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40842207R00000X, 207RG0100X
390200000X
GA066420207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3001215Medicaid
P00646975OtherRAILROAD MEDICARE
GA003110772FMedicaid
0009476173OtherAETNA
TN4173855OtherBCBS
KY7100033070OtherKENTUCKY MEDICAID