Provider Demographics
NPI:1740472794
Name:ROGER F SHAW III A PROFESSIONAL OPTOMETRY CORPORATION
Entity type:Organization
Organization Name:ROGER F SHAW III A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:HARDIN
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:225-687-2026
Mailing Address - Street 1:23855 EDEN ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3315
Mailing Address - Country:US
Mailing Address - Phone:225-687-2026
Mailing Address - Fax:225-687-2000
Practice Address - Street 1:23855 EDEN ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3315
Practice Address - Country:US
Practice Address - Phone:225-687-2026
Practice Address - Fax:225-687-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA754-055T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1151955Medicaid
LA1151955Medicaid