Basic Information
| Provider Information | |||||||||
| NPI: | 1538194675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 W MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946115641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107521000 | ||||||||
| FaxNumber: | 7076512743 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 W MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946115641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107521000 | ||||||||
| FaxNumber: | 7076512743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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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 | 207Q00000X | 036-113299 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | A80836 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | A80836 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.