Provider Demographics
NPI:1821476771
Name:SHAW, JACQUELYN (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:SHAW
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HICKSVILLE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3472
Mailing Address - Country:US
Mailing Address - Phone:267-339-7843
Mailing Address - Fax:
Practice Address - Street 1:109 W 27TH ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6208
Practice Address - Country:US
Practice Address - Phone:212-263-0040
Practice Address - Fax:212-263-8827
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298446207V00000X, 207VE0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program