Provider Demographics
NPI:1053329797
Name:SHAW, SPENCER (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
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:PO BOX 5801
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5801
Mailing Address - Country:US
Mailing Address - Phone:914-593-7880
Mailing Address - Fax:914-593-7881
Practice Address - Street 1:30 GREENRIDGE AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1237
Practice Address - Country:US
Practice Address - Phone:914-328-8555
Practice Address - Fax:914-593-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109224207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00600058OtherRR MEDICARE
NYE51307Medicare UPIN
NYP00600058OtherRR MEDICARE