Provider Demographics
NPI:1114085859
Name:SHIELDS, CHARLES Y (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:Y
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:10219 KINGSTON PIKE
Mailing Address - Street 2:STE 101
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3222
Mailing Address - Country:US
Mailing Address - Phone:865-539-3888
Mailing Address - Fax:865-539-0653
Practice Address - Street 1:10219 KINGSTON PIKE
Practice Address - Street 2:STE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3222
Practice Address - Country:US
Practice Address - Phone:865-539-3888
Practice Address - Fax:865-539-0653
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNODT1339152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
2788120001Medicare NSC