Provider Demographics
NPI:1144221623
Name:SHAW, DAPHNE NIZZA (MD)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:NIZZA
Last Name:SHAW
Suffix:
Gender:F
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1108 S HENDERSON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4430
Practice Address - Country:US
Practice Address - Phone:817-335-3255
Practice Address - Fax:817-338-9563
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL05922080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FE461OtherBCBS-TX
TX042962304Medicaid
TX042962304Medicaid
TX417921YMJCMedicare PIN