1154356491 NPI number — VINCENT LEE SHAW JR. MD

Table of content: VINCENT LEE SHAW JR. MD (NPI 1154356491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154356491 NPI number — VINCENT LEE SHAW JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
VINCENT
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1154356491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8490 PICARDY AVE
Provider Second Line Business Mailing Address:
BLDG 200
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-3731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-237-1754
Provider Business Mailing Address Fax Number:
225-237-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8490 PICARDY AVE
Provider Second Line Business Practice Location Address:
BLDG 100 STE A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-3731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-819-1170
Provider Business Practice Location Address Fax Number:
225-819-1179
Provider Enumeration Date:
07/12/2006

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: 207QS0010X , with the licence number:  026422 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 026422 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1058823 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 026422 . This is a "LA STATE LICENSE #" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 4J728YJGU . This is a "MEDICARE PTAN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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