Provider Demographics
NPI:1376587055
Name:SHAW, ROBERT N (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:N
Last Name:SHAW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 MERIDEN WATERBURY TPKE
Mailing Address - Street 2:
Mailing Address - City:MILLDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06467-0475
Mailing Address - Country:US
Mailing Address - Phone:860-621-1919
Mailing Address - Fax:860-628-5086
Practice Address - Street 1:1783 MERIDEN WATERBURY TPKE
Practice Address - Street 2:
Practice Address - City:MILLDALE
Practice Address - State:CT
Practice Address - Zip Code:06467-0475
Practice Address - Country:US
Practice Address - Phone:860-621-1919
Practice Address - Fax:860-628-5086
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001066111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001066CT01OtherANTHEM BCBS
U38497Medicare UPIN