Provider Demographics
NPI:1851361398
Name:SHAW, PETER K (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:K
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 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-791-3888
Mailing Address - Fax:207-828-7850
Practice Address - Street 1:331 VERANDA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5545
Practice Address - Country:US
Practice Address - Phone:207-828-2402
Practice Address - Fax:207-828-2425
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD9819207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME111080099Medicaid
MESX2310Medicare PIN
MED03869Medicare UPIN
ME111080099Medicaid