Provider Demographics
NPI:1679694996
Name:SHELINE, JONATHAN L (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L
Last Name:SHELINE
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2325
Mailing Address - Country:US
Mailing Address - Phone:919-956-4000
Mailing Address - Fax:
Practice Address - Street 1:112 SWIFT AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4883
Practice Address - Country:US
Practice Address - Phone:919-336-0566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2153865FMedicare PIN
NCE12636Medicare UPIN