Provider Demographics
NPI:1730119934
Name:SHIELDS, JACK M (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MAGNOLIA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-1759
Mailing Address - Country:US
Mailing Address - Phone:856-455-8833
Mailing Address - Fax:856-453-8358
Practice Address - Street 1:20 MAGNOLIA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-1759
Practice Address - Country:US
Practice Address - Phone:856-455-8833
Practice Address - Fax:856-453-8358
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA35038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3019501Medicaid
NJ3019501Medicaid
NJC54167Medicare UPIN