Healthcare Provider Details

I. General information

NPI: 1013412196
Provider Name (Legal Business Name): DARRAH RENEE SHIELDS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 COURTLAND BLVD
DELTONA FL
32738-8902
US

IV. Provider business mailing address

510 VENETIAN VILLA DR
NEW SMYRNA BEACH FL
32168-5348
US

V. Phone/Fax

Practice location:
  • Phone: 407-249-1234
  • Fax:
Mailing address:
  • Phone: 904-716-1574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME150685
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: