Provider Demographics
NPI:1679745962
Name:ROBERT P SHACKELFORD MD
Entity Type:Organization
Organization Name:ROBERT P SHACKELFORD MD
Other - Org Name:SULPHUR SPRINGS ORTHOPEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-439-6302
Mailing Address - Street 1:113 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-2138
Mailing Address - Country:US
Mailing Address - Phone:903-439-6302
Mailing Address - Fax:903-439-2765
Practice Address - Street 1:113 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2138
Practice Address - Country:US
Practice Address - Phone:903-439-6302
Practice Address - Fax:903-439-2765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0922332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0657500001OtherCIGNA GOVERNMENT SERVICES