Provider Demographics
NPI:1417969981
Name:SHELTON, ROY W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:W
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 1:1630 KILLINGSWORTH AVE
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2282
Mailing Address - Country:US
Mailing Address - Phone:417-777-2222
Mailing Address - Fax:417-777-2224
Practice Address - Street 1:1630 KILLINGSWORTH AVE
Practice Address - Street 2:SUITE 2-A
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2282
Practice Address - Country:US
Practice Address - Phone:417-777-2222
Practice Address - Fax:417-777-2224
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR3920156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA12124Medicare UPIN