Basic Information
| Provider Information | |||||||||
| NPI: | 1578541439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHACKELFORD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442954871 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1224 TROTWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442954871 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2006 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20169 | SC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 15386 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 87131 | 01 | TN | BCBS | OTHER | 300039095 | 01 | TN | RR MEDICARE | OTHER | 3050164 | 05 | TN | MEDICAID |