Provider Demographics
NPI:1699982686
Name:SHACKELFORD, ALAN (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:SHACKELFORD
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 1:646 DIXON RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-8747
Mailing Address - Country:US
Mailing Address - Phone:303-440-4250
Mailing Address - Fax:
Practice Address - Street 1:14001 E ILIFF AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1405
Practice Address - Country:US
Practice Address - Phone:303-778-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33551174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33551OtherSTATE LICENSE NUMBER