Provider Demographics
NPI:1285633065
Name:SHIELDS, CHRISTOPHER C (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:C
Last Name:SHIELDS
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 1:1125 W ALAMEDA RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6143
Mailing Address - Country:US
Mailing Address - Phone:208-237-1151
Mailing Address - Fax:
Practice Address - Street 1:1125 W ALAMEDA RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6143
Practice Address - Country:US
Practice Address - Phone:208-237-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4528207Q00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003933100Medicaid
ID11153301Medicare PIN
IDE08603Medicare UPIN