Provider Demographics
NPI:1104890680
Name:SHAW, HOLLIS EARL (MD)
Entity type:Individual
Prefix:DR
First Name:HOLLIS
Middle Name:EARL
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6242 E ARBOR AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1309
Mailing Address - Country:US
Mailing Address - Phone:480-668-7060
Mailing Address - Fax:480-668-5815
Practice Address - Street 1:6242 E ARBOR AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1309
Practice Address - Country:US
Practice Address - Phone:480-668-7060
Practice Address - Fax:480-668-5815
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ15515207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ170879Medicaid
AZ170879Medicaid
AZ15515Medicare ID - Type UnspecifiedMEDICARE