Provider Demographics
NPI:1376555771
Name:SHOCKET, IRA DAVID (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:DAVID
Last Name:SHOCKET
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:PO BOX 37229
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297
Mailing Address - Country:US
Mailing Address - Phone:240-485-5210
Mailing Address - Fax:301-625-6906
Practice Address - Street 1:106 IRVING ST NW
Practice Address - Street 2:STE 205
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2927
Practice Address - Country:US
Practice Address - Phone:202-829-0170
Practice Address - Fax:202-829-2927
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD19539207RG0100X
MDD0043028207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD598291001Medicaid
DC021403600Medicaid
DC100005118OtherMEDICARE RAILROAD
DC100005118OtherMEDICARE RAILROAD
F26592Medicare UPIN