Provider Demographics
NPI:1801040688
Name:JOHN R SHAW MD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JOHN R SHAW MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-781-3800
Mailing Address - Street 1:3719 ARLINGTON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2652
Mailing Address - Country:US
Mailing Address - Phone:951-781-3800
Mailing Address - Fax:951-781-1973
Practice Address - Street 1:3719 ARLINGTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2652
Practice Address - Country:US
Practice Address - Phone:951-781-3800
Practice Address - Fax:951-781-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15265261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39479Medicare UPIN