Provider Demographics
NPI:1366404105
Name:SHOCKEY, BRIAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:SHOCKEY
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 1:2419 CHICKASAW BLVD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1466
Mailing Address - Country:US
Mailing Address - Phone:580-223-6767
Mailing Address - Fax:580-226-2977
Practice Address - Street 1:2419 CHICKASAW BLVD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1466
Practice Address - Country:US
Practice Address - Phone:580-223-6767
Practice Address - Fax:580-226-2977
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100202500AMedicaid
OK100202500AMedicaid
OK800522353Medicare ID - Type Unspecified
OK248414603Medicare PIN