Provider Demographics
NPI:1588625198
Name:SHELTON, THOMAS O (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:O
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 1:1406 WILD CAT HOLW
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-3622
Mailing Address - Country:US
Mailing Address - Phone:512-330-0918
Mailing Address - Fax:512-328-3694
Practice Address - Street 1:1406 WILD CAT HOLW
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-3622
Practice Address - Country:US
Practice Address - Phone:512-330-0918
Practice Address - Fax:512-328-3694
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD52062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN43348OtherSTATE LICENSE
AZ5608OtherSTATE LICENSE
TX139107015Medicaid
TN7455OtherSTATE LICENSE
TX8F2670Medicare PIN
P00478275Medicare PIN
C21722Medicare UPIN
AZ5608OtherSTATE LICENSE
TN7455OtherSTATE LICENSE