Provider Demographics
NPI:1932242542
Name:SHOCKLEY, TRISTAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:J
Last Name:SHOCKLEY
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 1:9900 GREENBELT RD
Mailing Address - Street 2:SUITE E117
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2255
Mailing Address - Country:US
Mailing Address - Phone:240-786-1001
Mailing Address - Fax:
Practice Address - Street 1:14205 PARK CENTER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5246
Practice Address - Country:US
Practice Address - Phone:240-786-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD038330208100000X
MDD0068884208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation