Basic Information
Provider Information | |||||||||
NPI: | 1700821790 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIELDS | ||||||||
FirstName: | SAM | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2550 NORTH HOLLYWOOD WAY | ||||||||
Address2: | SUITE 209 | ||||||||
City: | BURBANK | ||||||||
State: | CA | ||||||||
PostalCode: | 915055019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8185570135 | ||||||||
FaxNumber: | 8185571394 | ||||||||
Practice Location | |||||||||
Address1: | 1401 GARCES HIGHWAY | ||||||||
Address2: |   | ||||||||
City: | DELANO | ||||||||
State: | CA | ||||||||
PostalCode: | 932153690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6617215262 | ||||||||
FaxNumber: | 6617215254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | C28997 | CA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00C289970 | 01 | CA | CALOPTIMA | OTHER | C28997 | 01 | CA | BLUE CROSS | OTHER | 00C289970 | 05 | CA |   | MEDICAID | 00C289970 | 01 | CA | BLUE SHIELD | OTHER | 050608CA33806 | 01 | CA | DELANO TRAILBLAZER | OTHER | P00282262 | 01 | CA | DELANO RAILROAD | OTHER |