Provider Demographics
NPI:1356674493
Name:SHAW, BRIAN TERRY (DO,)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:TERRY
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9089 BASELINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1295
Mailing Address - Country:US
Mailing Address - Phone:909-483-0505
Mailing Address - Fax:909-483-0508
Practice Address - Street 1:9089 BASELINE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1295
Practice Address - Country:US
Practice Address - Phone:909-483-0505
Practice Address - Fax:909-483-0508
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A10900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine