Provider Demographics
NPI:1093742256
Name:SHAW, SHELLY F (OD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:F
Last Name:SHAW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 TUSCULUM BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4056
Mailing Address - Country:US
Mailing Address - Phone:423-639-8128
Mailing Address - Fax:423-798-9204
Practice Address - Street 1:1000 TUSCULUM BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4056
Practice Address - Country:US
Practice Address - Phone:423-639-8128
Practice Address - Fax:423-798-9204
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3941301Medicare ID - Type Unspecified
TNU66902Medicare UPIN