Provider Demographics
NPI:1437192630
Name:SHELTON, CHARLES H III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:SHELTON
Suffix:III
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:187 SKYLAR DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9359
Practice Address - Country:US
Practice Address - Phone:304-425-1960
Practice Address - Fax:304-487-3514
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV198022085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7200011000Medicaid
VA1437192630Medicaid
WVP00716522OtherRR MEDICARE
WVP00716522OtherRR MEDICARE
VA920000121Medicare PIN
WV0878362Medicare PIN
F66409Medicare UPIN
VA1437192630Medicaid
WV920004832Medicare PIN
VA920006736Medicare PIN
WV7200011000Medicaid