Provider Demographics
NPI:1013412196
Name:SHIELDS, DARRAH RENEE (MD)
Entity Type:Individual
Prefix:
First Name:DARRAH
Middle Name:RENEE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 VENETIAN VILLA DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-5348
Mailing Address - Country:US
Mailing Address - Phone:904-716-1574
Mailing Address - Fax:
Practice Address - Street 1:596 COURTLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-8902
Practice Address - Country:US
Practice Address - Phone:407-249-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME150685208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program