Healthcare Provider Details

I. General information

NPI: 1558499640
Provider Name (Legal Business Name): RAYMOND CALVIN SHACKELFORD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MT PLEASANT RD
HERNANDO MS
38632-1909
US

IV. Provider business mailing address

8815 MILLBRANCH RD
SOUTHAVEN MS
38671-2312
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-4448
  • Fax: 662-429-5975
Mailing address:
  • Phone: 662-393-4161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD589-94300
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: