Provider Demographics
NPI:1407017908
Name:SHAW, WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 N WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-1875
Mailing Address - Country:US
Mailing Address - Phone:609-567-0200
Mailing Address - Fax:609-567-3492
Practice Address - Street 1:600 PEMBERTON BROWNS MILLS RD
Practice Address - Street 2:
Practice Address - City:PEMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08068-1537
Practice Address - Country:US
Practice Address - Phone:609-894-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09126300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0302457Medicaid
NJ0302457Medicaid