Healthcare Provider Details

I. General information

NPI: 1669899720
Provider Name (Legal Business Name): LUCUS DEAN SHELTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107
US

IV. Provider business mailing address

PO BOX 3570
SALT LAKE CITY UT
84110-3570
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7000
  • Fax: 770-701-6675
Mailing address:
  • Phone: 801-727-2056
  • Fax: 770-701-6675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.064786
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number10742194-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: