Provider Demographics
NPI:1578633236
Name:SHACKELFORD, ROBERT P (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:P
Last Name:SHACKELFORD
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 1367
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482
Mailing Address - Country:US
Mailing Address - Phone:903-439-6302
Mailing Address - Fax:903-439-2765
Practice Address - Street 1:113 AIRPORT ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482
Practice Address - Country:US
Practice Address - Phone:903-439-6302
Practice Address - Fax:903-439-2765
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0922207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033213202Medicaid
TX0053NGOtherBCBS
TX033213203Medicaid
TX4617433OtherAETNA
TX612259Medicare PIN
TX4617433OtherAETNA
TX0053NGOtherBCBS