=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649417726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN SHELTON O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2009
-----------------------------------------------------
Last Update Date | 05/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 369 W CHURCH ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38351-2096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-968-5225
-----------------------------------------------------
Fax | 731-967-3291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 369 W CHURCH ST
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38351-2096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-968-5225
-----------------------------------------------------
Fax | 731-967-3291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2904
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------