Provider Demographics
NPI:1467426866
Name:SHAW- MC MINN, PETER G (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:SHAW- MC MINN
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 1:27830 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2201
Mailing Address - Country:US
Mailing Address - Phone:951-672-4971
Mailing Address - Fax:951-672-4083
Practice Address - Street 1:27830 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2201
Practice Address - Country:US
Practice Address - Phone:951-672-4971
Practice Address - Fax:951-672-4083
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6553T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ81412ZMedicaid
CA12069OtherI.E.H.P.
CA06612OtherMEDICAL EYE SERVICES
CA118498OtherEYEMED VISIONCARE
CA9516724971OtherVISION SERVICE PLAN
CAFC49172OtherSAFEGUARD
CA06612OtherMEDICAL EYE SERVICES
CAZZZ81412ZMedicaid