Provider Demographics
NPI:1700905999
Name:SHOCKLEY, WILLIAM R (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:SHOCKLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAT964152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0786430001OtherDURABLE MEDICAL EQUIPMENT
GAT97834Medicare UPIN
GA41ZCCLBMedicare ID - Type Unspecified