Provider Demographics
NPI:1831146042
Name:SHOCKLEY, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:SHOCKLEY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:2710 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 410
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5619
Practice Address - Country:US
Practice Address - Phone:319-272-5000
Practice Address - Fax:319-272-5264
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-17
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Provider Licenses
StateLicense IDTaxonomies
IA34175207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249706Medicaid
IA0249706Medicaid
IAG85000Medicare UPIN