Provider Demographics
NPI:1477662229
Name:SHOCKLEY, BRIAN EDWARD (D P M)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
Last Name:SHOCKLEY
Suffix:
Gender:M
Credentials:D P M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3710
Mailing Address - Country:US
Mailing Address - Phone:601-638-7520
Mailing Address - Fax:601-638-7541
Practice Address - Street 1:1814 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3710
Practice Address - Country:US
Practice Address - Phone:601-638-7520
Practice Address - Fax:601-638-7541
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS80142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5963224OtherAETNA
MS00119033Medicaid
LA1540447Medicaid
LA4800026580OtherRAILROAD MEDICARE
MS1851563OtherUNITED HEALTHCARE
MS4342670001OtherMEDICARE DME
MS5963224OtherAETNA
MS480026580OtherRAILROAD MEDICARE
LA1851563OtherUNITED HEALTHCARE
LA1540447Medicaid
LA1851563OtherUNITED HEALTHCARE
MS1851563OtherUNITED HEALTHCARE
LA4J434CP38Medicare ID - Type Unspecified