Provider Demographics
NPI:1184773103
Name:SHAW, HEATHER (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 FULTON ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3875
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-01056207RX0202X, 208M00000X
NC98010562083P0901X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2275598Medicare ID - Type Unspecified
NC891212PMedicare ID - Type Unspecified
G94074Medicare ID - Type Unspecified