Provider Demographics
NPI:1598763641
Name:SHAW, COLLIE BLEVINS (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLIE
Middle Name:BLEVINS
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2200 ADA AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4985
Mailing Address - Country:US
Mailing Address - Phone:501-327-3929
Mailing Address - Fax:501-329-3816
Practice Address - Street 1:2200 ADA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4985
Practice Address - Country:US
Practice Address - Phone:501-327-3929
Practice Address - Fax:501-329-3816
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC7970207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127214001Medicaid
ARF98367Medicare UPIN