Provider Demographics
NPI:1548251036
Name:SHELTON, MARK VANCE (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:VANCE
Last Name:SHELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1355
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-1355
Mailing Address - Country:US
Mailing Address - Phone:318-628-4123
Mailing Address - Fax:318-628-4125
Practice Address - Street 1:106 W BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-2760
Practice Address - Country:US
Practice Address - Phone:318-628-4123
Practice Address - Fax:318-628-4125
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAR005223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB64175Medicare UPIN