Provider Demographics
NPI:1720066830
Name:SHAW, COREY A (DO)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:A
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2539
Mailing Address - Country:US
Mailing Address - Phone:3464-304-6423
Mailing Address - Fax:
Practice Address - Street 1:PSC 819 BOX 4377
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09645-0044
Practice Address - Country:US
Practice Address - Phone:3495-682-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3020982085R0202X
VA01022032342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology