Healthcare Provider Details

I. General information

NPI: 1699982686
Provider Name (Legal Business Name): ALAN SHACKELFORD M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14001 E ILIFF AVE SUITE 118
AURORA CO
80014-1405
US

IV. Provider business mailing address

646 DIXON RD
BOULDER CO
80302-8747
US

V. Phone/Fax

Practice location:
  • Phone: 303-778-1131
  • Fax:
Mailing address:
  • Phone: 303-440-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number33551
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: