Provider Demographics
NPI:1902868110
Name:SHIELDS, J WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:WILLIAM
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 1:373 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1603
Mailing Address - Country:US
Mailing Address - Phone:585-424-5665
Mailing Address - Fax:585-424-1273
Practice Address - Street 1:373 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1603
Practice Address - Country:US
Practice Address - Phone:585-424-5665
Practice Address - Fax:585-424-1273
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130129207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005239003.Medicaid
JS16701BMedicare ID - Type Unspecified
D79119Medicare UPIN