Provider Demographics
NPI:1609875848
Name:SHIELDS, MICHAEL S (DO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:S
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4139
Mailing Address - Country:US
Mailing Address - Phone:270-685-4966
Mailing Address - Fax:270-686-8058
Practice Address - Street 1:221 ALLEN ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4139
Practice Address - Country:US
Practice Address - Phone:270-685-4966
Practice Address - Fax:270-686-8058
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0871DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000049823OtherANTHEM
KY77008712Medicaid
KY0634203Medicare PIN
T54587Medicare UPIN
KY1310350001Medicare NSC