Healthcare Provider Details

I. General information

NPI: 1679694996
Provider Name (Legal Business Name): JONATHAN L. SHELINE MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SWIFT AVE
DURHAM NC
27705-4883
US

IV. Provider business mailing address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2325
US

V. Phone/Fax

Practice location:
  • Phone: 919-336-0566
  • Fax:
Mailing address:
  • Phone: 919-956-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29199
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: