Provider Demographics
NPI:1407136187
Name:SHAW, PRAVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:PRAVIN
Middle Name:
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:PO BOX 3699
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8699
Mailing Address - Country:US
Mailing Address - Phone:714-668-2500
Mailing Address - Fax:714-668-2515
Practice Address - Street 1:1190 BAKER ST STE 100
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4105
Practice Address - Country:US
Practice Address - Phone:714-668-2500
Practice Address - Fax:714-668-2515
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine