Healthcare Provider Details

I. General information

NPI: 1245345743
Provider Name (Legal Business Name): MICHAEL S DESHIELDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NEW YORK AVE
TRENTON NJ
08638-3913
US

IV. Provider business mailing address

20 N WOODBURY TURNERSVILLE RD
BLACKWOOD NJ
08012-2888
US

V. Phone/Fax

Practice location:
  • Phone: 609-393-8000
  • Fax:
Mailing address:
  • Phone: 856-374-6740
  • Fax: 856-374-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number25MA04362400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number25MA04362400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: