1417969981 NPI number — DR. ROY W SHELTON MD

Table of content: DR. ROY W SHELTON MD (NPI 1417969981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417969981 NPI number — DR. ROY W SHELTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELTON
Provider First Name:
ROY
Provider Middle Name:
W
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:
1417969981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1630 KILLINGSWORTH AVE
Provider Second Line Business Mailing Address:
SUITE 2-A
Provider Business Mailing Address City Name:
BOLIVAR
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65613-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-777-2222
Provider Business Mailing Address Fax Number:
417-777-2224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 KILLINGSWORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 2-A
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-777-2222
Provider Business Practice Location Address Fax Number:
417-777-2224
Provider Enumeration Date:
08/13/2006

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: 156FX1100X , with the licence number:  MDR3920 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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