Provider Demographics
NPI:1255359386
Name:SHIELDS, JUSTIN L III (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:L
Last Name:SHIELDS
Suffix:III
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 1555
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-1555
Mailing Address - Country:US
Mailing Address - Phone:850-484-4775
Mailing Address - Fax:850-484-4775
Practice Address - Street 1:540 FONTAINE ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2019
Practice Address - Country:US
Practice Address - Phone:850-484-4775
Practice Address - Fax:850-484-4775
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45060207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE17823Medicare UPIN
FL17610Medicare ID - Type Unspecified