Provider Demographics
NPI:1205247582
Name:SHIELDS, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 GREENVILLE AVE
Mailing Address - Street 2:SUITE # 433
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1910
Mailing Address - Country:US
Mailing Address - Phone:972-576-2920
Mailing Address - Fax:972-617-3930
Practice Address - Street 1:307 E OVILLA RD
Practice Address - Street 2:SUITE # 100
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-3898
Practice Address - Country:US
Practice Address - Phone:972-576-2920
Practice Address - Fax:972-617-3930
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1232407174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist