Provider Demographics
NPI:1972590776
Name:SHIELDS, CHARLES ROBERT (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
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 1:330 S 5TH ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5825
Mailing Address - Country:US
Mailing Address - Phone:580-242-1224
Mailing Address - Fax:580-242-1279
Practice Address - Street 1:330 S 5TH ST
Practice Address - Street 2:SUITE 305
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5825
Practice Address - Country:US
Practice Address - Phone:580-242-1224
Practice Address - Fax:580-242-1279
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22588174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC86422Medicare UPIN