Healthcare Provider Details

I. General information

NPI: 1588651715
Provider Name (Legal Business Name): CARL RANDOLPH SHELTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3407
US

IV. Provider business mailing address

6086 AUBURN CT
BURLINGTON KY
41005-8022
US

V. Phone/Fax

Practice location:
  • Phone: 407-681-2241
  • Fax: 407-679-2779
Mailing address:
  • Phone: 304-809-5312
  • Fax: 859-918-6625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number16669
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number45121
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number16669
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number45121
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: