Provider Demographics
NPI:1174594295
Name:SHELTON, SHARON L (DO)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:L
Last Name:SHELTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SHARON
Other - Middle Name:S
Other - Last Name:FAWAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2460 OLD MOULTRIE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:904-293-0299
Mailing Address - Fax:
Practice Address - Street 1:2984 S RIDGEWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-7527
Practice Address - Country:US
Practice Address - Phone:386-428-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260457400Medicaid
FLF93640Medicare UPIN
FL51934Medicare ID - Type Unspecified