Provider Demographics
NPI:1659544054
Name:D. DOUGLAS SHAW
Entity Type:Organization
Organization Name:D. DOUGLAS SHAW
Other - Org Name:ORTHOTEKNICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:D.
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:802-864-9909
Mailing Address - Street 1:312 COMMERCE ST
Mailing Address - Street 2:UNIT 10
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7832
Mailing Address - Country:US
Mailing Address - Phone:802-864-9909
Mailing Address - Fax:
Practice Address - Street 1:312 COMMERCE ST
Practice Address - Street 2:UNIT 10
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7832
Practice Address - Country:US
Practice Address - Phone:802-864-9909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT054 2771OtherBLUE CROSS BLUE SHIELD
VT0009187Medicaid
NY01060791Medicaid
VT054 2771OtherBLUE CROSS BLUE SHIELD