Provider Demographics
NPI:1477729168
Name:GARY N. SHIELDS DPM LLC
Entity Type:Organization
Organization Name:GARY N. SHIELDS DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-5211
Mailing Address - Street 1:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:
Practice Address - Street 1:340 BANTAM RD
Practice Address - Street 2:SUITE 1-B
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3318
Practice Address - Country:US
Practice Address - Phone:860-567-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041318600Medicaid
CT4624525OtherAETNA
CT6145090001OtherDMEPOS
CT6240129OtherCIGNA
CT614459OtherCONNECTICARE
CT6145090001Medicare NSC