Healthcare Provider Details

I. General information

NPI: 1194803619
Provider Name (Legal Business Name): CAROL SHACKLETON, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 20TH STREET
GOTHENBURG NE
69138-1237
US

IV. Provider business mailing address

918 20TH STREET
GOTHENBURG NE
69138-1237
US

V. Phone/Fax

Practice location:
  • Phone: 308-537-7131
  • Fax: 308-537-7310
Mailing address:
  • Phone: 308-537-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16620
License Number StateNE

VIII. Authorized Official

Name: CAROL SHACKLETON
Title or Position: OWNER
Credential: M.D.
Phone: 308-537-7131