Healthcare Provider Details

I. General information

NPI: 1477662229
Provider Name (Legal Business Name): BRIAN EDWARD SHOCKLEY D P M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 MISSION 66
VICKSBURG MS
39180-3710
US

IV. Provider business mailing address

1814 MISSION 66
VICKSBURG MS
39180-3710
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-7520
  • Fax: 601-638-7541
Mailing address:
  • Phone: 601-638-7520
  • Fax: 601-638-7541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberMS80142
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: