Provider Demographics
NPI:1154398642
Name:KOSTAKOGLU SHIELDS, LALE (MD)
Entity type:Individual
Prefix:
First Name:LALE
Middle Name:
Last Name:KOSTAKOGLU SHIELDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LALE
Other - Middle Name:
Other - Last Name:KOSTAKOGLU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0817
Practice Address - Country:US
Practice Address - Phone:434-924-9333
Practice Address - Fax:434-243-3938
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012676782085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH23620Medicare UPIN
NY88B241Medicare ID - Type Unspecified