1396971255 NPI number — DR. MOLLY DUDLEY SHIELDS M.D.

Table of content: DR. MOLLY DUDLEY SHIELDS M.D. (NPI 1396971255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396971255 NPI number — DR. MOLLY DUDLEY SHIELDS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIELDS
Provider First Name:
MOLLY
Provider Middle Name:
DUDLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396971255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1355 CENTRAL PKWY S
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232-5057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-349-9300
Provider Business Mailing Address Fax Number:
210-366-2558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3903 WISEMAN BLVD
Provider Second Line Business Practice Location Address:
SUITE # 215
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78251-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-675-6724
Provider Business Practice Location Address Fax Number:
210-675-1759
Provider Enumeration Date:
06/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: P6271 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3233710-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com