Provider Demographics
NPI:1366411555
Name:SHIELDS, MARK D (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:SHIELDS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:24221 CALLE DE LA LOUISA
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7638
Mailing Address - Country:US
Mailing Address - Phone:949-465-8155
Mailing Address - Fax:949-465-8159
Practice Address - Street 1:24221 CALLE DE LA LOUISA
Practice Address - Street 2:SUITE 200
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7638
Practice Address - Country:US
Practice Address - Phone:949-588-8700
Practice Address - Fax:949-465-8159
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-09-29
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Provider Licenses
StateLicense IDTaxonomies
CAG77342207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F85976Medicare UPIN
CAWG77342EMedicare ID - Type Unspecified