Provider Demographics
NPI:1306828710
Name:SHAW, ROLAND DESHAWN
Entity Type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:DESHAWN
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 1/2 W 99TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3919
Mailing Address - Country:US
Mailing Address - Phone:323-777-5016
Mailing Address - Fax:323-777-2016
Practice Address - Street 1:414 W 99TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3919
Practice Address - Country:US
Practice Address - Phone:323-777-5016
Practice Address - Fax:323-777-2016
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor