Basic Information
| Provider Information | |||||||||
| NPI: | 1679694996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELINE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 FAYETTEVILLE ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199564000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 112 SWIFT AVE | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277054883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193360566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 29199 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.