Provider Demographics
NPI:1750321436
Name:SHAW, JOHN L (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:SHAW
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9650 LEYLAND DRIVE, APT 405
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363
Mailing Address - Country:US
Mailing Address - Phone:423-620-4025
Mailing Address - Fax:828-687-6285
Practice Address - Street 1:438 E VANN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-7202
Practice Address - Country:US
Practice Address - Phone:423-278-1700
Practice Address - Fax:423-278-1708
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN05330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31440261Medicaid
D68917Medicare UPIN
TN31440261Medicare PIN
TNP00414418Medicare PIN