Basic Information
| Provider Information | |||||||||
| NPI: | 1467646604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 N EVERGREEN AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445422273 | ||||||||
| FaxNumber: | 8568459398 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 N EVERGREEN AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568458010 | ||||||||
| FaxNumber: | 8568459398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 03/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MB09021500 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0356042 | 05 | NJ | MEDICAID |