Provider Demographics
NPI:1417344011
Name:SHAW, WILLIAM BRADY (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADY
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 1:1125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-632-5660
Mailing Address - Fax:573-632-5859
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5660
Practice Address - Fax:573-632-5859
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019016550208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation