Healthcare Provider Details

I. General information

NPI: 1467537159
Provider Name (Legal Business Name): RICK A SHACKET DO MD H
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 N GRANITE REEF RD STE 12
SCOTTSDALE AZ
85257-3998
US

IV. Provider business mailing address

8 BILTMORE ESTATES DRIVE # 201
PHOENIX AZ
85016
US

V. Phone/Fax

Practice location:
  • Phone: 602-492-9919
  • Fax: 602-263-3697
Mailing address:
  • Phone: 602-920-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4257
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number4257
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: