Provider Demographics
NPI:1881672392
Name:SHELTON, PHILIP D (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:#100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:440 PLUMAS BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-5071
Practice Address - Country:US
Practice Address - Phone:530-799-3301
Practice Address - Fax:530-749-3496
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG589642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300106518OtherMEDICARE ID
CA00G589640Medicaid
300130622OtherMEDICARE ID
300130622OtherMEDICARE ID
CA00G589640Medicaid