Provider Demographics
NPI:1588035976
Name:TACKITT, SHANE M (DO)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:M
Last Name:TACKITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2700 E BROAD ST
Mailing Address - Street 2:DEPARTMENT INTERNAL MEDICINE
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5899
Mailing Address - Country:US
Mailing Address - Phone:682-242-6470
Mailing Address - Fax:682-622-2092
Practice Address - Street 1:2700 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5899
Practice Address - Country:US
Practice Address - Phone:682-242-6470
Practice Address - Fax:682-622-2092
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXS5274208M00000X, 390200000X, 207R00000X
WA390200000X
TXBP10058725390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program