Provider Demographics
NPI:1831159615
Name:SHAMBLIN, JACK F III (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:F
Last Name:SHAMBLIN
Suffix:III
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 1:94 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9284
Mailing Address - Country:US
Mailing Address - Phone:304-264-8933
Mailing Address - Fax:304-264-8846
Practice Address - Street 1:94 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9284
Practice Address - Country:US
Practice Address - Phone:304-264-8933
Practice Address - Fax:304-264-8846
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17829207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0060852000Medicaid
WV050065778OtherRAILROAD MEDICARE
WV0762922Medicare PIN
WV0060852000Medicaid