1467426866 NPI number — PETER G SHAW- MC MINN O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467426866 NPI number — PETER G SHAW- MC MINN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW- MC MINN
Provider First Name:
PETER
Provider Middle Name:
G
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:
1467426866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27830 BRADLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92586-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-672-4971
Provider Business Mailing Address Fax Number:
951-672-4083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27830 BRADLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92586-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-672-4971
Provider Business Practice Location Address Fax Number:
951-672-4083
Provider Enumeration Date:
02/14/2006

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:  OPT 6553T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ81412Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12069 . This is a "I.E.H.P." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 06612 . This is a "MEDICAL EYE SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 118498 . This is a "EYEMED VISIONCARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 9516724971 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FC49172 . This is a "SAFEGUARD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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