Provider Demographics
NPI:1326106931
Name:SHAW, KENNETH STEVEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:STEVEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:997 WINDMILL PKWY
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6666
Mailing Address - Country:US
Mailing Address - Phone:706-787-7155
Mailing Address - Fax:706-787-2666
Practice Address - Street 1:997 WINDMILL PKWY
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6666
Practice Address - Country:US
Practice Address - Phone:706-787-7155
Practice Address - Fax:706-787-2666
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist