Provider Demographics
NPI:1669552600
Name:SHAW, ISAAC BERNARD (MD)
Entity type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:BERNARD
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 1:12000 STONE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-3291
Mailing Address - Fax:575-759-7243
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.051823208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM25829823Medicaid
NM8HL317OtherMEDICARE PROVIDER#
NMHSZ196OtherMEDICARE PART B
AZH62094Medicare UPIN