Provider Demographics
NPI:1033348792
Name:SHAW, DAVID JOSEPH (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOSEPH
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 ZEAMER AVENUE
Mailing Address - Street 2:673D MDG
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:673D MDG
Practice Address - City:JBER ELMENDORF AFB
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005570207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1648361Medicaid
AKK167485Medicare PIN