Provider Demographics
NPI:1629357892
Name:SHELTON, RANDAL C (DO)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:C
Last Name:SHELTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S NEVADA AVENUE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401
Mailing Address - Country:US
Mailing Address - Phone:970-249-7751
Mailing Address - Fax:970-249-5029
Practice Address - Street 1:836 S. TOWNSEND UNIT A
Practice Address - Street 2:MOUNTAIN PEAKS FAMILY PRACTICE
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:970-615-9120
Practice Address - Fax:970-240-1139
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172631207Q00000X
CODR.0053162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO349127ZV3YOtherMEDICARE B PTAN FOR MTN PEAKS FAMILY PRACTICE
CO349127YS6EOtherMEDICARE B PTAN FOR LBN: OLATHE COMMUNITY CLINIC
CO91737818Medicaid
P01721833OtherRAILROAD WORKERS MEDICARE FOR MTN PEAKS FAMILY PRACTICE
CO349127YTYKOtherMEDICARE PTAN SAN JUAN FAMILY MEDICINE
COP01382230OtherRAILROAD WORKERS MEDICARE FOR CEDAREDE DOCTOR'S OFFICE