Provider Demographics
NPI:1164691689
Name:W J SHIELDS M D
Entity Type:Organization
Organization Name:W J SHIELDS M D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HADSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-874-0320
Mailing Address - Street 1:PO BOX 2696
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23609-0696
Mailing Address - Country:US
Mailing Address - Phone:757-874-0320
Mailing Address - Fax:757-989-0276
Practice Address - Street 1:914 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:VA
Practice Address - Zip Code:23692-2156
Practice Address - Country:US
Practice Address - Phone:757-874-0320
Practice Address - Fax:757-989-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024156207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA002959OtherANTHEM
VA5969115Medicaid
VA002959OtherANTHEM
VA5969115Medicaid