Provider Demographics
NPI:1598215063
Name:SHAW, FURTARDO
Entity Type:Individual
Prefix:MR
First Name:FURTARDO
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 GRACE CUNNINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-6757
Mailing Address - Country:US
Mailing Address - Phone:850-728-6553
Mailing Address - Fax:
Practice Address - Street 1:39 GRACE CUNNINGHAM RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32352-6757
Practice Address - Country:US
Practice Address - Phone:850-728-6553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-09
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA306712252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA306712Medicaid
FLA306712Medicaid