Provider Demographics
NPI:1265528665
Name:SHAW, LACY B (OD)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:B
Last Name:SHAW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:5615-B JACKSON ST EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303
Mailing Address - Country:US
Mailing Address - Phone:318-442-7787
Mailing Address - Fax:318-443-1654
Practice Address - Street 1:5615-B JACKSON ST EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303
Practice Address - Country:US
Practice Address - Phone:318-442-7787
Practice Address - Fax:318-443-1654
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA734-081T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
72-0756964OtherFARA
72-0756964OtherFIRST HEALTH
72-0756964OtherOFFICE OF GROUP BENEFITS
72-0756964OtherUNITED HEALTHCARE
LA4081OtherEYEMED
72-0756964OtherAETNA
720756964OtherVISION SERVICE PLAN
LA1153486Medicaid
410008037OtherRAILROAD MEDICARE
72-0756964OtherPPO PLUS
72-0756964OtherAMERICAN LIFE CARE
72-0756964OtherHUMANA
16670OtherSTARMOUNT/ALWAYS VISION
72-0756964OtherMAIL HANDLERS
72-0756964OtherDEFINITY HEALTH
85731OtherSPECTERA
720756964OtherVISION SERVICE PLAN
72-0756964OtherHUMANA