Provider Demographics
NPI:1821066135
Name:SHAW, EDWARD F
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:F
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 1:1295 PORTLAND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2731
Mailing Address - Country:US
Mailing Address - Phone:585-544-3430
Mailing Address - Fax:585-544-3473
Practice Address - Street 1:1295 PORTLAND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2731
Practice Address - Country:US
Practice Address - Phone:585-544-3430
Practice Address - Fax:585-544-3473
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00002739156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00450564Medicaid
NY8720OtherBLUE CROSS BLUE SHIELD
NY103245CTOtherPREFERRED CARE
NY0553600001Medicare ID - Type UnspecifiedMEDICARE