Provider Demographics
NPI:1417058108
Name:SHAW, JOHN F (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
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 1:2201 NE 52ND ST
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-7074
Mailing Address - Country:US
Mailing Address - Phone:954-420-5110
Mailing Address - Fax:954-420-5112
Practice Address - Street 1:2201 NE 52ND ST
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-7074
Practice Address - Country:US
Practice Address - Phone:954-420-5110
Practice Address - Fax:954-420-5112
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME10357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD51596Medicare UPIN
FL06523Medicare ID - Type Unspecified