Provider Demographics
NPI:1740933316
Name:SHELTON, ROBERT JR
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SHELTON
Suffix:JR
Gender:M
Credentials:
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 181698
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76096-1698
Mailing Address - Country:US
Mailing Address - Phone:214-900-8360
Mailing Address - Fax:
Practice Address - Street 1:3504 MT VERNON AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-2527
Practice Address - Country:US
Practice Address - Phone:214-900-8360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410Medicaid