Organization
MOUNTAIN WEST DERM - BLACKHART PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY B SHACKELTON MD (OWNER)
(775) 283-4086
Entity
Organization
Contact information
Practice address
341 NW MEDICAL LOOP STE 110, ROSEBURG, OR 97471-5546
(541) 440-2165
(541) 440-8932
Mailing address
341 NW MEDICAL LOOP STE 110, ROSEBURG, OR 97471-5546
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Enumeration date
10/01/2021
Last updated
10/04/2021
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