Provider Demographics
NPI:1578890570
Name:SHAW, BRIAN R (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DATES DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1345
Mailing Address - Country:US
Mailing Address - Phone:607-272-0460
Mailing Address - Fax:
Practice Address - Street 1:201 DATES DR STE 101
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1345
Practice Address - Country:US
Practice Address - Phone:215-840-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015512207R00000X
NY310717-01207RC0000X, 207RI0011X
NJ25MB08946200207RC0000X
PAOT012650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease