Provider Demographics
NPI:1073535456
Name:SHIELDS, GARY N (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:N
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:DPM
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 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:386-774-5251
Practice Address - Street 1:340 BANTAM RD
Practice Address - Street 2:SUITE 1-B
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3318
Practice Address - Country:US
Practice Address - Phone:860-567-1600
Practice Address - Fax:860-567-1606
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000820213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6240129OtherCINGA
FL041318600Medicaid
SC261444569OtherPALMETTO GBA DME
CT6145090001OtherDMEPOS
CT008003499Medicaid
CT614459OtherCONNECTICARE
SC261444569OtherPALMETTO GBA DME
CT480001042Medicare PIN
FL4380280001Medicare NSC
CT614459OtherCONNECTICARE
CT6145090001OtherDMEPOS