Provider Demographics
NPI:1619947769
Name:SHELTON, RICHARD RUSSELL JR (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:RUSSELL
Last Name:SHELTON
Suffix:JR
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:4095 S LEE ST
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3647
Practice Address - Country:US
Practice Address - Phone:770-932-8519
Practice Address - Fax:770-533-4798
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043775208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA302587OtherWELLCARE
GA52684584OtherBCBS
GA5402578OtherAETNA PPO
GA8238671OtherCIGNA
GA000754157MMedicaid
GA000754157PMedicaid
GA000754157QMedicaid
GA1939869OtherUNITED HEALTHCARE
GA302571OtherWELLCARE
GA000754157NMedicaid
GA000754157RMedicaid
GA10032982OtherAMERIGROUP
GA302567OtherWELLCARE
GA2276934OtherAETNA HMO
GA302588OtherWELLCARE
GA000754157PMedicaid
GA000754157MMedicaid