Provider Demographics
NPI:1952369225
Name:SHAW, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SHAW
Suffix:
Gender:M
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:PO BOX 3699
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8699
Mailing Address - Country:US
Mailing Address - Phone:949-552-8585
Mailing Address - Fax:949-552-8615
Practice Address - Street 1:4950 BARRANCA PKWY
Practice Address - Street 2:SUITE 103C
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4671
Practice Address - Country:US
Practice Address - Phone:949-552-8585
Practice Address - Fax:949-552-8615
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39931207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48022Medicare UPIN
CAWG39931AMedicare ID - Type Unspecified