Provider Demographics
NPI:1154309557
Name:SHAW, CHARLENE G (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:G
Last Name:SHAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 S R 436
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5664
Mailing Address - Country:US
Mailing Address - Phone:407-831-5252
Mailing Address - Fax:
Practice Address - Street 1:985 SR 436
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5664
Practice Address - Country:US
Practice Address - Phone:407-831-5252
Practice Address - Fax:561-367-7886
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009795400Medicaid
FLP01234568OtherRAILROAD MC
FL009795400Medicaid
FL13331YMedicare PIN
FLP01234568OtherRAILROAD MC
FLH65922Medicare UPIN