Provider Demographics
NPI:1265672117
Name:DR. MICHAEL P. SHAW, A PROFESSIONAL CORPORATION, INC.
Entity Type:Organization
Organization Name:DR. MICHAEL P. SHAW, A PROFESSIONAL CORPORATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-667-9339
Mailing Address - Street 1:222 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-7272
Mailing Address - Country:US
Mailing Address - Phone:209-667-9339
Mailing Address - Fax:209-664-0505
Practice Address - Street 1:2020 STANDIFORD AVE STE B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6530
Practice Address - Country:US
Practice Address - Phone:209-522-9339
Practice Address - Fax:209-525-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35996174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty