Provider Demographics
NPI:1235115056
Name:SHAW, MICHAEL D (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2163
Mailing Address - Country:US
Mailing Address - Phone:662-615-2503
Mailing Address - Fax:662-615-2554
Practice Address - Street 1:400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2163
Practice Address - Country:US
Practice Address - Phone:662-615-2503
Practice Address - Fax:662-615-2554
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18567207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04776258Medicaid
MS04776258Medicaid
MS930002987Medicare PIN