Provider Demographics
NPI:1770692550
Name:SHAW, KEVIN MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:SHAW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-1721
Mailing Address - Country:US
Mailing Address - Phone:973-300-1850
Mailing Address - Fax:973-300-1840
Practice Address - Street 1:94 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1721
Practice Address - Country:US
Practice Address - Phone:973-300-1850
Practice Address - Fax:973-300-1840
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ023501Medicare PIN