Basic Information
| Provider Information | |||||||||
| NPI: | 1740499490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIELD | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1508 WILLOW LAWN DR | ||||||||
| Address2: | STE 117 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232303421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042888327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1508 WILLOW LAWN DR | ||||||||
| Address2: | STE 117 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232303421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042888327 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101241679 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 224564 | 01 | ANTHEM | OTHER | 1740499490 | 05 | VA | MEDICAID |