Provider Demographics
NPI:1013928480
Name:SHAW, JOHN ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:SHAW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 W BANCROFT ST
Mailing Address - Street 2:# 352215
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-3200
Mailing Address - Country:US
Mailing Address - Phone:419-536-9294
Mailing Address - Fax:419-536-9340
Practice Address - Street 1:5821 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-1403
Practice Address - Country:US
Practice Address - Phone:419-536-9294
Practice Address - Fax:419-536-9340
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3892152W00000X
MI4901003796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20139Medicare UPIN
P00246808Medicare ID - Type Unspecified
OHSH0595816Medicare ID - Type Unspecified
OH03169Medicare UPIN
MION16960Medicare ID - Type Unspecified
MI90-0-E8-1085-0Medicare UPIN