Provider Demographics
NPI:1811954423
Name:SHAW, KOUSHIK K (MD)
Entity type:Individual
Prefix:
First Name:KOUSHIK
Middle Name:K
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12319 N MOPAC EXPY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2414
Mailing Address - Country:US
Mailing Address - Phone:512-694-8888
Mailing Address - Fax:512-973-3036
Practice Address - Street 1:12319 N MOPAC EXPY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2414
Practice Address - Country:US
Practice Address - Phone:512-694-8888
Practice Address - Fax:512-973-3036
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2013-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXM0272208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170313401Medicaid
TXP00196306OtherRRMCR
TXI21421Medicare UPIN
TX170313401Medicaid