Basic Information
Provider Information | |||||||||
NPI: | 1700422516 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEPPARD | ||||||||
FirstName: | ALEJANDRO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2401 W DARTMOUTH ST | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485047158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8109627001 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 303 S MILL ST | ||||||||
Address2: |   | ||||||||
City: | CLIO | ||||||||
State: | MI | ||||||||
PostalCode: | 484202307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106878700 | ||||||||
FaxNumber: | 8106878724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2019 | ||||||||
LastUpdateDate: | 11/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5501019406 | MI | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.