Provider Demographics
NPI:1316002686
Name:SHELTON, JEREMY BRADFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:BRADFORD
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 1:10833 LE CONTE AVE RM 66-134
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1738
Mailing Address - Country:US
Mailing Address - Phone:310-206-8177
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE RM 66-134
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1738
Practice Address - Country:US
Practice Address - Phone:310-206-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105091208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology