Provider Demographics
NPI:1245201938
Name:SHIELDS, CLARENCE L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:L
Last Name:SHIELDS
Suffix:JR
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 1:6801 PARK TER
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:310-665-7228
Mailing Address - Fax:310-641-3978
Practice Address - Street 1:6801 PARK TER
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-665-7228
Practice Address - Fax:310-641-3978
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29184174400000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33852Medicare UPIN