Provider Demographics
NPI:1023036290
Name:SHIELDS, JESSIE (MD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
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 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:SUTIE 3500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1300
Mailing Address - Fax:304-691-1375
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:SUTIE 3500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1300
Practice Address - Fax:304-691-1375
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22273208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006269Medicaid
4188681Medicare PIN