Provider Demographics
NPI:1205877826
Name:SHELTON, PENNY L (MD)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-589-3100
Mailing Address - Fax:740-589-3127
Practice Address - Street 1:2131 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-589-3127
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22917207Q00000X
OH35-08-3516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2467781OtherMOLINA MEDICAID
WV1811329000Medicaid
OH310917085132OtherCARESOURCE MEDICAID
P00175244OtherRR MEDICARE
OH000000182413OtherUNISON MEDICAID
000000328527OtherANTHEM BCBS
001714156OtherMOUNTAIN STATE BCBS
OH2467781Medicaid
OH2467781OtherMOLINA MEDICAID
P00175244OtherRR MEDICARE