Provider Demographics
NPI:1073543971
Name:SHELTON, ROGER D (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:SHELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7315 212TH ST SW
Mailing Address - Street 2:#204
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7610
Mailing Address - Country:US
Mailing Address - Phone:425-771-3311
Mailing Address - Fax:425-775-9844
Practice Address - Street 1:7315 212TH ST SW
Practice Address - Street 2:#204
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-771-3311
Practice Address - Fax:425-775-9844
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00015787207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1502608Medicaid
WAA09197Medicare UPIN