Basic Information
| Provider Information | |||||||||
| NPI: | 1629357892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | RANDAL | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S NEVADA AVENUE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702497751 | ||||||||
| FaxNumber: | 9702495029 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 S. TOWNSEND UNIT A | ||||||||
| Address2: | MOUNTAIN PEAKS FAMILY PRACTICE | ||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706159120 | ||||||||
| FaxNumber: | 9702401139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2011 | ||||||||
| LastUpdateDate: | 08/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 172631 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0053162 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 349127ZV3Y | 01 | CO | MEDICARE B PTAN FOR MTN PEAKS FAMILY PRACTICE | OTHER | 349127YS6E | 01 | CO | MEDICARE B PTAN FOR LBN: OLATHE COMMUNITY CLINIC | OTHER | 91737818 | 05 | CO | MEDICAID | P01721833 | 01 | RAILROAD WORKERS MEDICARE FOR MTN PEAKS FAMILY PRACTICE | OTHER | 349127YTYK | 01 | CO | MEDICARE PTAN SAN JUAN FAMILY MEDICINE | OTHER | P01382230 | 01 | CO | RAILROAD WORKERS MEDICARE FOR CEDAREDE DOCTOR'S OFFICE | OTHER |