Provider Demographics
NPI:1902003775
Name:MARK W. SHELTON M.D. PLLC
Entity Type:Organization
Organization Name:MARK W. SHELTON M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-832-8186
Mailing Address - Street 1:397 WALLACE RD
Mailing Address - Street 2:STE 414
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-4854
Mailing Address - Country:US
Mailing Address - Phone:816-832-8186
Mailing Address - Fax:816-832-8310
Practice Address - Street 1:397 WALLACE RD
Practice Address - Street 2:STE 414
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-4854
Practice Address - Country:US
Practice Address - Phone:816-832-8186
Practice Address - Fax:816-832-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN245792086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3730870Medicare ID - Type Unspecified