Provider Demographics
NPI:1508831942
Name:SHAW, J ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:ELAINE
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
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 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1505 STATE HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-8950
Practice Address - Country:US
Practice Address - Phone:903-675-1725
Practice Address - Fax:903-675-7668
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121323301Medicaid
TX121323304OtherTHSTEPS-MEDICAID
TX121323301Medicaid
TX82Z312Medicare ID - Type Unspecified
TX370011061Medicare PIN