Provider Demographics
NPI:1922192780
Name:SHELTON, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:SHELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-1485
Practice Address - Fax:817-338-1841
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG56072080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130235808Medicaid
TX00U87ZOtherBCBSTX GRP PIN
TX101290OtherSUPERIOR PIN
TX123840100OtherFIRSTCARE PIN
1750369203OtherGRP NPI NUMBER
TX88V630OtherBCBSTX IND PIN
TX1580397OtherCIGNA PIN
TX1640363OtherFIRSTHEALTH PIN
TX4311144OtherAETNA PIN
TX77035OtherUHC PIN
TX10028903OtherAMERIGROUP PIN
TX77035OtherUHC PIN
E76941Medicare UPIN