Healthcare Provider Details

I. General information

NPI: 1932242542
Provider Name (Legal Business Name): TRISTAN J SHOCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14205 PARK CENTER DR SUITE 204
LAUREL MD
20707-5246
US

IV. Provider business mailing address

9900 GREENBELT RD SUITE E117
LANHAM MD
20706-2255
US

V. Phone/Fax

Practice location:
  • Phone: 240-786-1001
  • Fax:
Mailing address:
  • Phone: 240-786-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD038330
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD0068884
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: