Provider Demographics
NPI:1518968080
Name:HAIRSTON-JONES, SHELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:HAIRSTON-JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10150 CENTENNIAL PKWY STE 230
Mailing Address - Street 2:C/O JERALD THOMPSON
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4123
Mailing Address - Country:US
Mailing Address - Phone:801-432-2571
Mailing Address - Fax:801-838-7105
Practice Address - Street 1:7490 NEW TECHNOLOGY WAY
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703
Practice Address - Country:US
Practice Address - Phone:240-566-1613
Practice Address - Fax:240-566-1620
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054663207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0054663OtherSTATE LICENSE NUMBER
MD912602300Medicaid
MDH01473Medicare UPIN
MDD0054663OtherSTATE LICENSE NUMBER