Provider Demographics
NPI:1386844926
Name:SHAW, MICHAEL KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9730
Mailing Address - Country:US
Mailing Address - Phone:541-412-1152
Mailing Address - Fax:541-412-1842
Practice Address - Street 1:555 5TH ST
Practice Address - Street 2:SUITE #1
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9730
Practice Address - Country:US
Practice Address - Phone:541-412-1152
Practice Address - Fax:541-412-1842
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine