Provider Demographics
NPI:1093829772
Name:SHELGREN, JOHN DONALD JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DONALD
Last Name:SHELGREN
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 1:427 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3051
Mailing Address - Country:US
Mailing Address - Phone:863-293-5100
Mailing Address - Fax:863-293-5300
Practice Address - Street 1:427 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3051
Practice Address - Country:US
Practice Address - Phone:863-293-5100
Practice Address - Fax:863-293-5300
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39638208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066624600Medicaid
FL53639OtherBLUE CROSS BLUE SHIELD
FL53639OtherBLUE CROSS BLUE SHIELD
FL066624600Medicaid