Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1100X | Ophthalmic | MDR3920 | MO |
NPI | 1417969981 |
---|---|
Provider Name | Dr. Roy W Shelton |
First Address | Bolivar, MO 65613-2282 |
Second Address | Bolivar, MO 65613-2282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A12124 | (02) | MO |