Provider Demographics
NPI:1336497759
Name:BRIT S SHACKLEY MD APC
Entity Type:Organization
Organization Name:BRIT S SHACKLEY MD APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-397-5667
Mailing Address - Street 1:100 W CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3010
Mailing Address - Country:US
Mailing Address - Phone:626-397-5667
Mailing Address - Fax:626-397-2156
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:626-397-5667
Practice Address - Fax:626-397-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107373207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA107373OtherCA MED LICENSE