Provider Demographics
NPI:1073506432
Name:SHAW, DAVID LEE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
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 1:907 MAR WALT DRIVE
Mailing Address - Street 2:SUITE 2021
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6960
Mailing Address - Country:US
Mailing Address - Phone:850-863-0006
Mailing Address - Fax:850-863-0012
Practice Address - Street 1:907 MAR WALT DRIVE
Practice Address - Street 2:SUITE 2021
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6960
Practice Address - Country:US
Practice Address - Phone:850-863-0006
Practice Address - Fax:850-863-0012
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME232362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17403OtherBCBS FL
FL17403OtherBLUE CROSS BLUE SHIELD
D61971Medicare UPIN
17403AMedicare PIN