Provider Demographics
NPI:1770617854
Name:SHELTON, TOMMY WARREN (MD)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:WARREN
Last Name:SHELTON
Suffix:
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 1:350 HOSPITAL WAY
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2872
Mailing Address - Country:US
Mailing Address - Phone:606-425-4298
Mailing Address - Fax:606-425-4299
Practice Address - Street 1:350 HOSPITAL WAY
Practice Address - Street 2:SUITE 270
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2872
Practice Address - Country:US
Practice Address - Phone:606-425-4298
Practice Address - Fax:606-425-4299
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41582208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00675001OtherMEDICARE PTAN