Healthcare Provider Details

I. General information

NPI: 1992365597
Provider Name (Legal Business Name): DR. ANTHONY LEE SHELTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 ARLINGTON ST
ADA OK
74820-4045
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax: 580-436-1159
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34719
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34719
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier34719
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOKLAHOMA BOARD OF MEDICAL LICENSURE AND SUPERVISION

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: