Healthcare Provider Details

I. General information

NPI: 1992768253
Provider Name (Legal Business Name): WILLIAM JENNINGS SHIELDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 DENBIGH BLVD
GRAFTON VA
23692
US

IV. Provider business mailing address

PO BOX 2696
NEWPORT NEWS VA
23609
US

V. Phone/Fax

Practice location:
  • Phone: 757-874-0320
  • Fax: 757-989-0276
Mailing address:
  • Phone: 757-874-0320
  • Fax: 757-989-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101024156
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: