Provider Demographics
NPI:1245207075
Name:SHAW, IZABELA S
Entity Type:Individual
Prefix:DR
First Name:IZABELA
Middle Name:S
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 VISTA RIVER DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-7862
Mailing Address - Country:US
Mailing Address - Phone:813-653-1245
Mailing Address - Fax:813-643-3090
Practice Address - Street 1:3119 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-5632
Practice Address - Country:US
Practice Address - Phone:813-643-3242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83318207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264906300Medicaid
FLE7050WMedicare PIN
FL264906300Medicaid