Healthcare Provider Details

I. General information

NPI: 1538780820
Provider Name (Legal Business Name): DANIEL WAYNE SHIELDS JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 05/23/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142 / KADENA AIR BASE OKINAWA
APO AP
96368
US

IV. Provider business mailing address

18TH MEDICAL GROUP UNIT 5142 / KADENA AIR BASE OKINAWA
APO AP
96368
US

V. Phone/Fax

Practice location:
  • Phone: 198-960-4817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102206807
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0102206807
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: