Provider Demographics
NPI:1447211883
Name:SHIELDS, JAMES K (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:K
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:128 W MARKET STREET
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:IN
Practice Address - Zip Code:47995
Practice Address - Country:US
Practice Address - Phone:219-279-2264
Practice Address - Fax:219-279-2279
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027166A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000334269OtherANTHEM PROVIDER NUMBER
IN100196860Medicaid
IND94544Medicare UPIN
INP00114544Medicare PIN
IN100196860Medicaid