Provider Demographics
NPI:1639462013
Name:SHAW, MARK A (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:SHAW
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 E PENNSYLVANIA AVENUE
Mailing Address - Street 2:SUITE H
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025
Mailing Address - Country:US
Mailing Address - Phone:760-743-5544
Mailing Address - Fax:760-743-5306
Practice Address - Street 1:925 E PENNSYLVANIA AVENUE
Practice Address - Street 2:SUITE H
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-743-5544
Practice Address - Fax:760-743-5306
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA531237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194897496OtherMEDI-CAL