Provider Demographics
NPI:1316923493
Name:SHOCKLEY, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:SHOCKLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 CANTON ST STE 240
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2326
Mailing Address - Country:US
Mailing Address - Phone:339-204-9516
Mailing Address - Fax:814-594-6987
Practice Address - Street 1:690 CANTON ST STE 240
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-2326
Practice Address - Country:US
Practice Address - Phone:339-204-9516
Practice Address - Fax:814-594-6987
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73011207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3078744Medicaid
MA3078744Medicaid
B87033Medicare UPIN
MAJ1124301Medicare PIN