Provider Demographics
NPI:1033123138
Name:SHAW, LINDA (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5347
Mailing Address - Fax:314-268-4015
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5347
Practice Address - Fax:314-268-4015
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05358000208000000X
MO2012004803208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3859908Medicaid
NJ571360B3LMedicare ID - Type Unspecified
NJ3859908Medicaid