Provider Demographics
NPI:1437171741
Name:SHAW, DOUGLAS E (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:SHAW
Suffix:
Gender:M
Credentials:DC
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 904
Mailing Address - Street 2:
Mailing Address - City:ANNA MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34216-0904
Mailing Address - Country:US
Mailing Address - Phone:231-632-4380
Mailing Address - Fax:
Practice Address - Street 1:515 W 14TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4059
Practice Address - Country:US
Practice Address - Phone:231-941-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDS004118111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950B850130OtherBCBS ID
MI0B85013Medicare ID - Type Unspecified