Provider Demographics
NPI:1558499640
Name:SHACKELFORD, RAYMOND CALVIN (OD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:CALVIN
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 1:8815 MILLBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2312
Mailing Address - Country:US
Mailing Address - Phone:662-393-4161
Mailing Address - Fax:
Practice Address - Street 1:2350 MT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1909
Practice Address - Country:US
Practice Address - Phone:662-429-4448
Practice Address - Fax:662-429-5975
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOD589-94300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087049Medicaid
MS00087049Medicaid