Provider Demographics
NPI:1457322729
Name:LEE, SHAW S (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAW
Middle Name:S
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SOUTHPARK CIR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2963
Mailing Address - Country:US
Mailing Address - Phone:804-524-8882
Mailing Address - Fax:804-524-8882
Practice Address - Street 1:114 SOUTHPARK CIR
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2963
Practice Address - Country:US
Practice Address - Phone:804-524-8882
Practice Address - Fax:804-524-8882
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA159442OtherSOUTHERN HEALTH SERVICES
VA5447517OtherAETNA
VA217407OtherANTHEM BC BS OF VA
VAU12909Medicare UPIN