Provider Demographics
NPI:1760436570
Name:SHIELDS, RODERICK A (MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:A
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:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-1188
Mailing Address - Country:US
Mailing Address - Phone:601-891-8465
Mailing Address - Fax:601-891-8468
Practice Address - Street 1:128 EARL CLARK DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-6604
Practice Address - Country:US
Practice Address - Phone:601-891-8465
Practice Address - Fax:601-891-8468
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E50922Medicare UPIN
MS080004340Medicare PIN