Healthcare Provider Details

I. General information

NPI: 1679765523
Provider Name (Legal Business Name): TIMOTHY LEE SHELTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 PLEASANT HILL RD STE A
DULUTH GA
30096-6379
US

IV. Provider business mailing address

4300 PLEASANT HILL RD STE A
DULUTH GA
30096-6379
US

V. Phone/Fax

Practice location:
  • Phone: 770-904-9602
  • Fax:
Mailing address:
  • Phone: 770-778-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number059870
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number059870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: