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Individual
DR. CAROL L SHACKLETON
Active
Individual
DR. CAROL L SHACKLETON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
16620
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03042
STATE BC/BS
NE
01
—
099905
MEDICARE GROUP
NE
05
—
100253852-00
—
NE
01
—
11595205
CAQH
NE
01
—
6366
MIDLANDS CHOICE
NE
Enumeration date
06/23/2006
Last updated
02/09/2012
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