1720187347 NPI number — DR. JACQUELYN SHAW M.D.

Table of content: DR. JACQUELYN SHAW M.D. (NPI 1720187347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720187347 NPI number — DR. JACQUELYN SHAW M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
JACQUELYN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1720187347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 TERRACE AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HASBROUCK HEIGHTS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-288-6330
Provider Business Mailing Address Fax Number:
201-288-6331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 TERRACE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASBROUCK HEIGHTS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-288-6330
Provider Business Practice Location Address Fax Number:
201-288-6331
Provider Enumeration Date:
09/21/2006

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: 207VE0102X , with the licence number:  MA55112 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 74437 . This is a "GREAT WEST" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2043630 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1528267 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2749N1 . This is a "WELLCHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5180001 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8217906 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P2884936 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 820584930 . This is a "HORIZON BC BS OF NJ" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: J30559 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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