Provider Demographics
NPI:1497917165
Name:SHAW, TREVECCA KERRY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TREVECCA
Middle Name:KERRY
Last Name:SHAW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 BELMONT AVE
Mailing Address - Street 2:#1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1130
Mailing Address - Country:US
Mailing Address - Phone:330-747-3910
Mailing Address - Fax:330-747-3930
Practice Address - Street 1:2406 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1008
Practice Address - Country:US
Practice Address - Phone:502-775-1711
Practice Address - Fax:502-443-0369
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00338213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000614278OtherANTHEM
OH2919864Medicaid
OH2919864Medicaid
OH$$$$$$$$$00OtherBWC
OH4526302Medicare PIN