Provider Demographics
NPI:1023497344
Name:SHAW, JACOB ISRAEL (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ISRAEL
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 1:617 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1601
Mailing Address - Country:US
Mailing Address - Phone:802-864-0693
Mailing Address - Fax:708-763-7232
Practice Address - Street 1:789 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4924
Practice Address - Country:US
Practice Address - Phone:802-864-0693
Practice Address - Fax:028-606-6138
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036144497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program