Provider Demographics
NPI:1700440252
Name:SHACKLETTE, ALEX HUNTER (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:HUNTER
Last Name:SHACKLETTE
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 1:350 W 11TH ST RM 4083
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4108
Mailing Address - Country:US
Mailing Address - Phone:317-491-6000
Mailing Address - Fax:
Practice Address - Street 1:350 W 11TH ST RM 4083
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4108
Practice Address - Country:US
Practice Address - Phone:317-491-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program