Basic Information
Provider Information | |||||||||
NPI: | 1407802572 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHMOOKLER | ||||||||
FirstName: | BARRY | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 753 JOHNNIE DODDS BLVD | ||||||||
Address2: |   | ||||||||
City: | MT PLEASANT | ||||||||
State: | SC | ||||||||
PostalCode: | 294643054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432843400 | ||||||||
FaxNumber: | 8432843401 | ||||||||
Practice Location | |||||||||
Address1: | 3600 JOSEPH SIEWICK DR | ||||||||
Address2: |   | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220331709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7033913654 | ||||||||
FaxNumber: | 7033913049 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | D0021961 | MD | X |   | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZP0102X | D0021961 | MD | X |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | AS8058338 | 01 |   | DEA REGISTRATION # | OTHER | D0021961 | 01 | MD | MD MEDICAL LICENSE # | OTHER | MD13872 | 01 | DC | DC MEDICAL LICENSE # | OTHER |