Provider Demographics
NPI:1720019151
Name:SHELLITO, JOHN JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SHELLITO
Suffix:JR
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:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:1947 FOUNDERS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3548
Practice Address - Country:US
Practice Address - Phone:316-689-9124
Practice Address - Fax:316-613-4608
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS20502208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS836OtherPHS
KS12149403OtherMULTIPLAN
KS200152OtherHPK
KS003429OtherBCBS
KS100147290CMedicaid
KS16923OtherCOVENTRY
KS100147290CMedicaid
B68978Medicare UPIN