Provider Demographics
NPI:1437167772
Name:SHAW, RICHARD K (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
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 1:12 VILLA ROSA TER
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-7915
Mailing Address - Country:US
Mailing Address - Phone:203-882-8380
Mailing Address - Fax:203-882-8384
Practice Address - Street 1:12 VILLA ROSA TER
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-7915
Practice Address - Country:US
Practice Address - Phone:203-882-8380
Practice Address - Fax:203-882-8384
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018088207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001180884Medicaid
B37858Medicare UPIN
CT001180884Medicaid