Provider Demographics
NPI:1972666147
Name:SHIELDS, TED (DO)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:TEDDY
Other - Middle Name:DOUGLAS
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:108 N SHACKLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2840
Mailing Address - Country:US
Mailing Address - Phone:501-346-8116
Mailing Address - Fax:
Practice Address - Street 1:1710 MAYFIELD DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:844-215-0731
Practice Address - Fax:888-630-8885
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3420207PE0004X, 2083P0011X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE3420OtherSTATE LICENSE
AR148797003Medicaid
AR148797003Medicaid