Provider Demographics
NPI:1689601254
Name:SHACKLETON, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:SHACKLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 WICHERS DR
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3064
Mailing Address - Country:US
Mailing Address - Phone:504-347-5421
Mailing Address - Fax:504-340-5171
Practice Address - Street 1:2600 BELLE CHASSE HWY
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-7156
Practice Address - Country:US
Practice Address - Phone:504-391-7670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.014794207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1330493Medicaid
LAB89881Medicare UPIN
LA1330493Medicaid