Provider Demographics
NPI:1255468997
Name:SHACKELFORD, JOE L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:L
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 BRADSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3078
Mailing Address - Country:US
Mailing Address - Phone:251-639-7101
Mailing Address - Fax:251-639-7101
Practice Address - Street 1:685 SCHILLINGER RD S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-8922
Practice Address - Country:US
Practice Address - Phone:251-633-5011
Practice Address - Fax:251-633-5394
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-421-TA-151152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT-69059Medicare UPIN
AL58542Medicare ID - Type Unspecified