1003807538 NPI number — DR. CORNELL SHELTON MD

Table of content: DR. CORNELL SHELTON MD (NPI 1003807538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003807538 NPI number — DR. CORNELL SHELTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELTON
Provider First Name:
CORNELL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003807538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 BURKE CENTRE PKWY STE 390
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22015-3750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-978-1196
Provider Business Mailing Address Fax Number:
703-978-7762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PARK HILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22401-3387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-978-1196
Provider Business Practice Location Address Fax Number:
703-978-7762
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  0101251254 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: 80380 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1003807538 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3172970 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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