Provider Demographics
NPI:1902180235
Name:SHELTON, TRAVIS JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:JOHN
Last Name:SHELTON
Suffix:
Gender:M
Credentials:OD
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 429
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:WY
Mailing Address - Zip Code:82937-0429
Mailing Address - Country:US
Mailing Address - Phone:307-787-6123
Mailing Address - Fax:307-787-3351
Practice Address - Street 1:106 S.MAIN ST.
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:WY
Practice Address - Zip Code:82937-0429
Practice Address - Country:US
Practice Address - Phone:307-787-6123
Practice Address - Fax:307-787-3351
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY336T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist