Provider Demographics
NPI:1992768253
Name:SHIELDS, WILLIAM JENNINGS (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JENNINGS
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 2696
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23609
Mailing Address - Country:US
Mailing Address - Phone:757-874-0320
Mailing Address - Fax:757-989-0276
Practice Address - Street 1:914 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:VA
Practice Address - Zip Code:23692
Practice Address - Country:US
Practice Address - Phone:757-874-0320
Practice Address - Fax:757-989-0276
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024156207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA002959OtherBCBS
VA5969115Medicaid
VAOC09214Medicare ID - Type Unspecified
VA5969115Medicaid