Provider Demographics
NPI:1780810986
Name:SHAW, COLETTE (MD)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:STE 3390
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-6226
Mailing Address - Fax:215-923-1562
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:STE 3390
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-6226
Practice Address - Fax:215-923-1562
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4427332085R0204X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102615625Medicaid
NJ0266841Medicaid
NJ0266841Medicaid