Provider Demographics
NPI:1518978402
Name:SHAW, VANCE CLEVELAND (MD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:CLEVELAND
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HIGH POINT DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1503
Mailing Address - Country:US
Mailing Address - Phone:423-631-0731
Mailing Address - Fax:423-631-0732
Practice Address - Street 1:205 HIGH POINT DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1503
Practice Address - Country:US
Practice Address - Phone:423-631-0731
Practice Address - Fax:423-631-0732
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD20911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN300121608OtherTAX ID
TN3700419Medicare ID - Type Unspecified
TNE89253Medicare UPIN
TN103I088632Medicare PIN