1265528665 NPI number — LACY B SHAW O.D.

Table of content: LACY B SHAW O.D. (NPI 1265528665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265528665 NPI number — LACY B SHAW O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
LACY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265528665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5615-B JACKSON ST EXT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-442-7787
Provider Business Mailing Address Fax Number:
318-443-1654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5615-B JACKSON ST EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-442-7787
Provider Business Practice Location Address Fax Number:
318-443-1654
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  734-081T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 734-081T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 72-0756964 . This is a "FARA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "OFFICE OF GROUP BENEFITS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: LA4081 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 720756964 . This is a "VISION SERVICE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1153486 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410008037 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "PPO PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "AMERICAN LIFE CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16670 . This is a "STARMOUNT/ALWAYS VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "MAIL HANDLERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72-0756964 . This is a "DEFINITY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 85731 . This is a "SPECTERA" identifier . This identifiers is of the category "OTHER".




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