Provider Demographics
NPI:1669586798
Name:SHAW, KAILIE (MD)
Entity type:Individual
Prefix:
First Name:KAILIE
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME238672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC29783OtherBLUE CROSS BLUE SHIELD
FL049817300Medicaid
DC29783OtherBLUE CROSS BLUE SHIELD
FL29783YMedicare PIN