Provider Demographics
NPI:1114951449
Name:JUSTIN L. SHIELDS MD PA
Entity Type:Organization
Organization Name:JUSTIN L. SHIELDS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-380-0481
Mailing Address - Street 1:PO BOX 1555
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-1555
Mailing Address - Country:US
Mailing Address - Phone:850-484-4775
Mailing Address - Fax:850-484-8223
Practice Address - Street 1:540 FONTAINE ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2019
Practice Address - Country:US
Practice Address - Phone:850-484-4775
Practice Address - Fax:850-484-8223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45060207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17610Medicare ID - Type Unspecified
FLE17823Medicare UPIN