Provider Demographics
NPI:1053469361
Name:SHIELDS, MARTY W (MD)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:W
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-354-5585
Mailing Address - Fax:806-356-4673
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:954-399-4645
Practice Address - Fax:855-855-2792
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH 08142086S0129X
TXH0814208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX038142802Medicaid
NM47924772Medicaid
TXPO80T6168Medicaid
OK200234310 AMedicaid
TXPO80T6168Medicaid
TX8L9482Medicare PIN
TX80T616Medicare ID - Type Unspecified