Healthcare Provider Details

I. General information

NPI: 1225471832
Provider Name (Legal Business Name): DANIEL SHOCKET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 11 6093 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-5156
US

IV. Provider business mailing address

2326 MOUNTAIN CREST CIR
THOUSAND OAKS CA
91362-2655
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6225
  • Fax:
Mailing address:
  • Phone: 818-687-7313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2016-0271
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: