Provider Demographics
NPI:1467581348
Name:SHELTON, GARY RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RYAN
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 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:6060 PIEDMONT ROW DR S FL 8
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28287
Practice Address - Country:US
Practice Address - Phone:704-489-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00339207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907374Medicaid
NC145WAOtherBCBS
NC1467581348Medicaid
SCN0033AMedicaid
NC1467581348Medicaid
NC2065012Medicare PIN
NC5907374Medicaid