Provider Demographics
NPI:1336139914
Name:SHAW, ALAN H (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:H
Last Name:SHAW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-2624
Mailing Address - Country:US
Mailing Address - Phone:406-995-2792
Mailing Address - Fax:
Practice Address - Street 1:1650 MULKEY RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1186
Practice Address - Country:US
Practice Address - Phone:770-941-3633
Practice Address - Fax:770-944-9038
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA352213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000006113BMedicaid
LA1756369Medicaid
LA1756369Medicaid