Provider Demographics
NPI:1164526430
Name:SHAW, MARY NANNY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NANNY
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LANELL
Other - Last Name:NANNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3416 NORWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4010
Mailing Address - Country:US
Mailing Address - Phone:214-728-3488
Mailing Address - Fax:866-476-1204
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-0624
Practice Address - Fax:214-645-0078
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3120207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150150401Medicaid
TX150150401Medicaid
8770N5Medicare ID - Type Unspecified