Provider Demographics
NPI:1649417726
Name:SHELTON, JONATHAN (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-2096
Mailing Address - Country:US
Mailing Address - Phone:731-968-5225
Mailing Address - Fax:731-967-3291
Practice Address - Street 1:369 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-2096
Practice Address - Country:US
Practice Address - Phone:731-968-5225
Practice Address - Fax:731-967-3291
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515311Medicaid
TN4235338OtherBCBS
TN1515311Medicaid
TN6381990001Medicare NSC