Provider Demographics
NPI:1902218597
Name:SHAW, RAPHAEL NDEDE (MD)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:NDEDE
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 1:630 W 246TH ST APT 222
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-3632
Mailing Address - Country:US
Mailing Address - Phone:347-886-3075
Mailing Address - Fax:
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2600
Practice Address - Country:US
Practice Address - Phone:203-673-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-30
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56674207R00000X, 208M00000X, 207RI0200X
NY292465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04842339Medicaid