Provider Demographics
NPI:1699733683
Name:SHIELDS, GREGORY WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1928
Mailing Address - Country:US
Mailing Address - Phone:334-793-8087
Mailing Address - Fax:334-793-8191
Practice Address - Street 1:1108 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-793-8087
Practice Address - Fax:334-793-8191
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00014931207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000091248Medicaid
AL051007047OtherBCBS AL
FL061675300Medicaid
GA537850840BMedicaid
AL051007047OtherBCBS AL
GA537850840BMedicaid
AL000091248Medicaid