Provider Demographics
NPI:1568451730
Name:SHIELDS, RUSSELL BRENT (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:BRENT
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 1:425 N MEDICAL DR
Mailing Address - Street 2:STE 108
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-292-8444
Mailing Address - Fax:801-292-8476
Practice Address - Street 1:425 N MEDICAL DR
Practice Address - Street 2:STE 108
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-292-8444
Practice Address - Fax:801-292-8476
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1551991205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT04714Medicaid
UT04714Medicaid