Provider Demographics
NPI:1124448741
Name:SHACKLES, CHRISTOPHER M (DO, MPH)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:SHACKLES
Suffix:
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-5400
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK UNIVERSITY HOSPITAL
Practice Address - Street 2:101 NICHOLS ROAD
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-1791
Practice Address - Fax:631-444-7689
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306058-012085R0204X
NY946244208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
946244OtherUNIVERSITY RESIDENT SUFFIX