Provider Demographics
NPI:1023409729
Name:RUSSEL K SHAW, MD
Entity type:Organization
Organization Name:RUSSEL K SHAW, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-321-0060
Mailing Address - Street 1:247 SAN MARCOS AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1432
Mailing Address - Country:US
Mailing Address - Phone:407-321-0060
Mailing Address - Fax:407-323-2720
Practice Address - Street 1:247 SAN MARCOS AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1432
Practice Address - Country:US
Practice Address - Phone:407-321-0060
Practice Address - Fax:407-323-2720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD70641Medicare UPIN