Provider Demographics
NPI:1023111697
Name:SHELTON, CHARLES I JR (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:I
Last Name:SHELTON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:I
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1350 BULL LEA RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1247
Mailing Address - Country:US
Mailing Address - Phone:859-246-8000
Mailing Address - Fax:859-246-8043
Practice Address - Street 1:1350 BULL LEA RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1247
Practice Address - Country:US
Practice Address - Phone:859-246-8000
Practice Address - Fax:859-246-8043
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH011071OtherSTATE MEDICAL BOARD OF OHIO
KY02282OtherLICENSE NUMBER
KY02282OtherLICENSE NUMBER