Provider Demographics
NPI:1720227721
Name:SHIELDS, CHARLES L (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:L
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1045 S GUM SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9299
Mailing Address - Country:US
Mailing Address - Phone:270-554-6656
Mailing Address - Fax:270-441-4370
Practice Address - Street 1:1045 S GUM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9299
Practice Address - Country:US
Practice Address - Phone:270-554-6656
Practice Address - Fax:270-441-4370
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15548174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist