Provider Demographics
NPI:1073518833
Name:SHAW, ALBERT LOVELL (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:LOVELL
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:P.O. BOX 780
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-868-1109
Mailing Address - Fax:817-545-8266
Practice Address - Street 1:729 WEST BEDFORDEULESS ROAD
Practice Address - Street 2:SUITE 111
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053
Practice Address - Country:US
Practice Address - Phone:817-868-1109
Practice Address - Fax:817-545-8266
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8080207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0474496-01Medicaid
C21687Medicare UPIN
TXC21687Medicare UPIN
TX8937K0Medicare ID - Type Unspecified