Provider Demographics
NPI:1669644522
Name:WILLIAM R. SHOCKLEY, OD
Entity Type:Organization
Organization Name:WILLIAM R. SHOCKLEY, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-254-0200
Mailing Address - Street 1:47 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1948
Mailing Address - Country:US
Mailing Address - Phone:770-254-0200
Mailing Address - Fax:770-254-1281
Practice Address - Street 1:47 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1948
Practice Address - Country:US
Practice Address - Phone:770-254-0200
Practice Address - Fax:770-254-1281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0786430001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000443484BMedicaid
GAT97834Medicare UPIN
GA000443484BMedicaid
GA0786430001Medicare NSC