Provider Demographics
NPI:1134565682
Name:SHELTON, SCOTT (DO)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:HENRY FORD ALLEGIANCE HEALTH
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 HINCKLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-6152
Practice Address - Country:US
Practice Address - Phone:517-784-0588
Practice Address - Fax:517-784-3866
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN72760087Medicare PIN