Provider Demographics
NPI:1750431094
Name:SHACKELFORD, HOWARD L JR (MD)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:L
Last Name:SHACKELFORD
Suffix:JR
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:PO BOX 6824
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0921
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:46150 NATIONAL RD W
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-8715
Practice Address - Country:US
Practice Address - Phone:740-695-2443
Practice Address - Fax:304-233-6073
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11190208600000X, 2086S0127X, 208G00000X
OH35042925208600000X, 2086S0127X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0517748Medicaid
WV0129426000Medicaid
OH0534666Medicare ID - Type Unspecified
A72250Medicare UPIN
WV0534667Medicare ID - Type Unspecified