Provider Demographics
NPI:1073590071
Name:SHIELD, STEPHEN WYATT (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WYATT
Last Name:SHIELD
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1144 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3330
Practice Address - Country:US
Practice Address - Phone:757-259-0443
Practice Address - Fax:757-259-0450
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049643207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073590071Medicaid
VA00Y225A01OtherMEDICARE PTAN
VA17424OtherSENTERA
VA250532OtherANTHEM
VA84330OtherSOUTHERN HEALTH
VA00Y225A01OtherMEDICARE PTAN
00Y225A01Medicare PIN
VA00Y225A01OtherMEDICARE PTAN
VA030004465Medicare ID - Type UnspecifiedRAILROAD MEDICARE