Provider Demographics
NPI:1861581241
Name:SHIELDS, JERRY A (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:A
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:840 WALNUT STREET
Mailing Address - Street 2:SUITE 1440
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3105
Mailing Address - Fax:215-928-1140
Practice Address - Street 1:840 WALNUT STREET
Practice Address - Street 2:SUITE 1440
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-928-3105
Practice Address - Fax:215-928-1140
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD010685E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000032006Medicare ID - Type Unspecified