Provider Demographics
NPI:1689716656
Name:SHIELDS, KIRSTEN KATE (OD)
Entity Type:Individual
Prefix:MRS
First Name:KIRSTEN
Middle Name:KATE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 S BERNHARDT AVE
Mailing Address - Street 2:
Mailing Address - City:GERALD
Mailing Address - State:MO
Mailing Address - Zip Code:63037-2316
Mailing Address - Country:US
Mailing Address - Phone:573-764-5321
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH COUNTY CENTERWAY
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1009
Practice Address - Country:US
Practice Address - Phone:314-892-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002015853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU92188Medicare UPIN