Provider Demographics
NPI:1477672624
Name:TIMOTHY SHANE SHAW MD, PA
Entity Type:Organization
Organization Name:TIMOTHY SHANE SHAW MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-328-8080
Mailing Address - Street 1:210 WEST PARK DR.
Mailing Address - Street 2:STE 100
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-9226
Mailing Address - Country:US
Mailing Address - Phone:936-328-8080
Mailing Address - Fax:936-328-8505
Practice Address - Street 1:210 WEST PARK DR.
Practice Address - Street 2:STE 100
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9226
Practice Address - Country:US
Practice Address - Phone:936-328-8080
Practice Address - Fax:936-328-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1343207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176109001Medicaid
TX0079QSOtherBLUE CROSS BLUE SHIELD TEXAS
TXDD8565OtherMEDICARE RAILROAD
TX1316930183OtherNPI TYPE 1
TX1316930183OtherNPI TYPE 1
TXI40794Medicare UPIN