Basic Information
| Provider Information | |||||||||
| NPI: | 1619947769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 4095 S LEE ST | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305183647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709328519 | ||||||||
| FaxNumber: | 7709322595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 043775 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000754157N | 05 | GA | MEDICAID | 000754157Q | 05 | GA | MEDICAID | 302567 | 01 | GA | WELLCARE | OTHER | 302571 | 01 | GA | WELLCARE | OTHER | 2276934 | 01 | GA | AETNA HMO | OTHER | 302588 | 01 | GA | WELLCARE | OTHER | 8238671 | 01 | GA | CIGNA | OTHER | 000754157R | 05 | GA | MEDICAID | 1939869 | 01 | GA | UNITED HEALTHCARE | OTHER | 302587 | 01 | GA | WELLCARE | OTHER | 5402578 | 01 | GA | AETNA PPO | OTHER | 000754157M | 05 | GA | MEDICAID | 000754157P | 05 | GA | MEDICAID | 10032982 | 01 | GA | AMERIGROUP | OTHER | 52684584 | 01 | GA | BCBS | OTHER |