Provider Demographics
NPI:1376537753
Name:SHAW, RICHARD MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2755 ALAMO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1346
Mailing Address - Country:US
Mailing Address - Phone:805-210-7280
Mailing Address - Fax:805-210-7112
Practice Address - Street 1:2755 ALAMO ST
Practice Address - Street 2:#100
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1311
Practice Address - Country:US
Practice Address - Phone:805-210-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F99229Medicare UPIN