Basic Information
| Provider Information | |||||||||
| NPI: | 1073698213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | ANDREAE | ||||||||
| MiddleName: | AREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043876200 | ||||||||
| FaxNumber: | 9043870261 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043876200 | ||||||||
| FaxNumber: | 9043870261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME100983 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.