Provider Demographics
NPI:1437140365
Name:SHOCKLEY, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SHOCKLEY
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 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:3700 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0541
Practice Address - Country:US
Practice Address - Phone:812-473-0181
Practice Address - Fax:812-473-5822
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047527A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64297914Medicaid
IN000000501013OtherBCBS - DEACONESS GATEWAY
IN000000184048OtherBC
IN200155630Medicaid
IN000000193493OtherBCBS - DEACONESS MARY ST
IN000000193493OtherBCBS - DEACONESS MARY ST
KY64297914Medicaid
IN050054975Medicare ID - Type UnspecifiedRAILROAD
IN234380NMedicare ID - Type UnspecifiedMCARE # - DEACONESS
F78930Medicare UPIN