# CAROL SHACKLETON, M.D., P.C.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194803619
- **Authorized official:** CAROL SHACKLETON M.D. (OWNER)
- **Authorized official phone:** (308) 537-7131

## Contact information

- **Practice address:** 918 20TH STREET, GOTHENBURG, NE 69138-1237
- **Practice address phone:** (308) 537-7131
- **Practice address fax:** (308) 537-7310
- **Mailing address:** 918 20TH STREET, GOTHENBURG, NE 69138-1237
- **Mailing address phone:** (308) 537-7131

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 16620 | NE | Yes |

## Other

- **Enumeration date:** 11/01/2006
- **Last updated:** 02/09/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 03042 | BC/BS | NE |
| 01 | — | 099905 | MEDICARE GROUP | NE |
| 05 | — | 100253852-00 | — | NE |
| 01 | — | 11595205 | CAQH | NE |
| 01 | — | 280121 | MEDICARE PTAN | — |
| 01 | — | 6366 | MIDLANDS CHOICE | NE |