Provider Demographics
NPI:1740360189
Name:SHAW, CARL R (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:R
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-3199
Practice Address - Fax:682-885-7499
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL94772080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164136702Medicaid
TX164136708OtherMEDICAID CSHCN
TX164136707Medicaid
H90098Medicare UPIN
8C1387Medicare ID - Type Unspecified
TX164136707Medicaid