Healthcare Provider Details

I. General information

NPI: 1578551792
Provider Name (Legal Business Name): WALTER ROWEN SHELTON II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax: 601-914-1851
Mailing address:
  • Phone: 601-354-4488
  • Fax: 601-914-1851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number7054
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: