Basic Information
| Provider Information | |||||||||
| NPI: | 1841235009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024484041 | ||||||||
| FaxNumber: | 2022697825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024484041 | ||||||||
| FaxNumber: | 2022697825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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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 | 207L00000X | 0101234439 | VA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD040830 | DC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 289021 | 01 | VA | ANTHEM BCBS | OTHER | 005720800 | 05 | VA | MEDICAID | 1809123-000 | 01 | VA | MEDICAID - WV | OTHER | P00019895 | 01 | VA | MEDICARE - RR | OTHER |