Provider Demographics
NPI:1093793713
Name:SHAW, JACOB D (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:D
Last Name:SHAW
Suffix:
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 1:2251 N WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-3947
Mailing Address - Country:US
Mailing Address - Phone:316-686-6063
Mailing Address - Fax:316-686-4214
Practice Address - Street 1:2251 N WOODLAWN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-3947
Practice Address - Country:US
Practice Address - Phone:316-686-6063
Practice Address - Fax:316-686-4214
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1665152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS463279Medicaid
KS200262380AMedicaid
KS8141OtherPPK
KS267621OtherCOVENTRY-LOC#2
KS269147OtherCOVENTRY-LOC#1
KS200262380AMedicaid
KS650991Medicare PIN
KS463279Medicaid
KS8141OtherPPK