Provider Demographics
NPI:1629004759
Name:SHACKLETON, CAROL L (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:L
Last Name:SHACKLETON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-1237
Mailing Address - Country:US
Mailing Address - Phone:308-537-7131
Mailing Address - Fax:308-537-7310
Practice Address - Street 1:918 20TH STREET
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1237
Practice Address - Country:US
Practice Address - Phone:308-537-7131
Practice Address - Fax:308-537-7310
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE6366OtherMIDLANDS CHOICE
NE100253852-00Medicaid
NE11595205OtherCAQH
NE03042OtherSTATE BC/BS
NE099905OtherMEDICARE GROUP
NE03042OtherSTATE BC/BS
NE11595205OtherCAQH
NE6366OtherMIDLANDS CHOICE