Provider Demographics
NPI:1902824261
Name:SHAW, CLYDE E (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:E
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 1:300 N HIGHLAND AVE STE 550
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-7390
Mailing Address - Country:US
Mailing Address - Phone:903-957-7429
Mailing Address - Fax:903-957-7424
Practice Address - Street 1:300 N HIGHLAND AVE STE 550
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7390
Practice Address - Country:US
Practice Address - Phone:903-957-7429
Practice Address - Fax:903-957-7424
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2856208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100155410AMedicaid
TX129563607Medicaid
TX129563606Medicaid
OK100155410AMedicaid
TX129563606Medicaid