Provider Demographics
NPI:1407859796
Name:HAGER, SHELTON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELTON
Middle Name:
Last Name:HAGER
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 3A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-392-6200
Practice Address - Fax:423-392-6593
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10134706Medicaid
TN3325584Medicaid
TN3700592Medicare UPIN
TNCC0450Medicare PIN
TN0281780001Medicare PIN
H45217Medicare UPIN
TN0281780003Medicare PIN
TNP00164628Medicare PIN
VA10134706Medicaid
TN3325584Medicaid