Provider Demographics
NPI:1013267996
Name:SHIELDS, ALONZO JAMELLE (IDC)
Entity type:Individual
Prefix:
First Name:ALONZO
Middle Name:JAMELLE
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 788-260
Mailing Address - Street 2:2ND MARINE REGIMENT STATION
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8266
Mailing Address - Country:US
Mailing Address - Phone:334-370-7078
Mailing Address - Fax:
Practice Address - Street 1:REGIMENTAL AID STATION
Practice Address - Street 2:7TH MARINE HQ RAS
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:334-370-7078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL72446891710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman