Individual
BRADLEY DAVID SHEPHERD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1001 SUMMIT BLVD STE 200, BROOKHAVEN, GA 30319-6410
(770) 989-1668
(678) 388-1759
Mailing address
1001, ATHENS, GA 30601-3806
(706) 548-0008
(706) 369-9673
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
40842
TN
207RG0100X
Gastroenterology Physician
Primary
066420
GA
207RG0100X
Gastroenterology Physician
40842
TN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0009476173
AETNA
—
05
—
003110772F
—
GA
05
—
3001215
—
TN
01
—
4173855
BCBS
TN
01
—
7100033070
KENTUCKY MEDICAID
KY
01
—
P00646975
RAILROAD MEDICARE
—
Enumeration date
01/04/2007
Last updated
10/05/2018
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