Basic Information
| Provider Information | |||||||||
| NPI: | 1376555771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOCKET | ||||||||
| FirstName: | IRA | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37229 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404855210 | ||||||||
| FaxNumber: | 3016256906 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 IRVING ST NW | ||||||||
| Address2: | STE 205 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028290170 | ||||||||
| FaxNumber: | 2028292927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD19539 | DC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | D0043028 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 598291001 | 05 | MD | MEDICAID | 021403600 | 05 | DC | MEDICAID | 100005118 | 01 | DC | MEDICARE RAILROAD | OTHER |