Basic Information
Provider Information | |||||||||
NPI: | 1780668392 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAW | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10333 EL CAMINO REAL | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 934225808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10333 EL CAMINO REAL | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 934225808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054682000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2005 | ||||||||
LastUpdateDate: | 02/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 233206 | NY | N |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   | 207R00000X | 140998 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 204117100 | 01 | NY | PHCS | OTHER | 02709722 | 05 | NY |   | MEDICAID | EMPIRE BCBS | 01 | NY | 184SE1 | OTHER | 9431055 | 01 | NY | CIGNA | OTHER |