Provider Demographics
NPI:1669454500
Name:SHAW, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-355-1660
Mailing Address - Fax:314-355-2807
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:SUITE 205E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-355-1660
Practice Address - Fax:314-355-2807
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108388207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7486026OtherAETNA
MO138767OtherGHP
MO000000010051OtherESSENCE
MO116062OtherBCBS
MO407737OtherHEALTLINK
MOG73848OtherMERCY
MO0406305OtherUHC
MO209781301Medicaid
MO000000010051OtherESSENCE
MO407737OtherHEALTLINK
MOP00044860Medicare PIN