Provider Demographics
NPI:1487702205
Name:SHELTON, CORLISS R (MD)
Entity type:Individual
Prefix:
First Name:CORLISS
Middle Name:R
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 MILLIKEN AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6782
Mailing Address - Country:US
Mailing Address - Phone:909-484-9182
Mailing Address - Fax:909-476-0050
Practice Address - Street 1:7777 MILLIKEN AVE STE 350
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6782
Practice Address - Country:US
Practice Address - Phone:909-484-9182
Practice Address - Fax:909-476-0050
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine