Provider Demographics
NPI:1710410899
Name:SHAW, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
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 1:175 W COHAWKIN RD
Mailing Address - Street 2:STE C
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020-1145
Mailing Address - Country:US
Mailing Address - Phone:856-423-7700
Mailing Address - Fax:
Practice Address - Street 1:8011 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-1317
Practice Address - Country:US
Practice Address - Phone:610-449-2345
Practice Address - Fax:610-449-2577
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00355700213E00000X
PASC007080213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist