Provider Demographics
NPI:1134197676
Name:SHAW, JOHN L JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:SHAW
Suffix:JR
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:PO BOX 1446
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-1446
Mailing Address - Country:US
Mailing Address - Phone:731-427-9971
Mailing Address - Fax:731-427-9973
Practice Address - Street 1:379 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-240-1777
Practice Address - Fax:731-427-9973
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD07991208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3175518Medicaid
TN3175519Medicare PIN
TN3175518Medicaid
TN340006363Medicare PIN