Provider Demographics
NPI:1710945522
Name:SHELTON, THOMAS BERKLEY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BERKLEY
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 1:1325 WOLF PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1742
Mailing Address - Country:US
Mailing Address - Phone:901-252-3411
Mailing Address - Fax:901-763-4305
Practice Address - Street 1:1325 WOLF PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1742
Practice Address - Country:US
Practice Address - Phone:901-252-3400
Practice Address - Fax:901-763-4305
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14342208800000X
MS11619208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4666085OtherAETNA
7299460OtherCIGNA
12940660OtherPHCS
747572OtherFIRST HEALTH
TN0100720OtherBLUE CROSS
02110025100OtherQUAL CHOICE
211159OtherSOUTHERN HEALTH SERVICES
89422OtherBLUE CROSS AR
TN3021792Medicaid
381926OtherHEALTH LINK
4666085OtherAETNA
02110025100OtherQUAL CHOICE
MS340000137Medicare ID - Type Unspecified
340011659Medicare ID - Type UnspecifiedRAILROAD MEDICARE