Provider Demographics
NPI:1083709760
Name:SHAW, ROGER F III (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:F
Last Name:SHAW
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23855 EDEN ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3315
Mailing Address - Country:US
Mailing Address - Phone:225-687-4190
Mailing Address - Fax:225-687-2000
Practice Address - Street 1:23855 EDEN ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3315
Practice Address - Country:US
Practice Address - Phone:225-687-4190
Practice Address - Fax:225-687-2000
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA754-055T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1151955Medicaid
49094Medicare PIN