Healthcare Provider Details

I. General information

NPI: 1114951449
Provider Name (Legal Business Name): JUSTIN L. SHIELDS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 FONTAINE ST
PENSACOLA FL
32503-2019
US

IV. Provider business mailing address

PO BOX 1555
GULF BREEZE FL
32562-1555
US

V. Phone/Fax

Practice location:
  • Phone: 850-484-4775
  • Fax: 850-484-8223
Mailing address:
  • Phone: 850-484-4775
  • Fax: 850-484-8223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME45060
License Number StateFL

VIII. Authorized Official

Name: JUSTIN L SHIELDS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 850-380-0481