Provider Demographics
NPI:1598724072
Name:SHACKELFORD, JOHN H JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:SHACKELFORD
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5108
Mailing Address - Country:US
Mailing Address - Phone:508-862-7777
Mailing Address - Fax:
Practice Address - Street 1:1421 ORLEANS RD
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-2148
Practice Address - Country:US
Practice Address - Phone:508-778-4777
Practice Address - Fax:508-771-9555
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2104296Medicaid
MAJ28724OtherBCBS
MAAA35717OtherHPHC
MA2104296Medicaid
MAJ28724OtherBCBS