Provider Demographics
NPI:1104947316
Name:SHAW, JACK CHING (OPTICIAN)
Entity type:Individual
Prefix:MS
First Name:JACK
Middle Name:CHING
Last Name:SHAW
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2906 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7163
Mailing Address - Country:US
Mailing Address - Phone:773-525-1601
Mailing Address - Fax:773-435-4210
Practice Address - Street 1:2906 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7163
Practice Address - Country:US
Practice Address - Phone:773-525-1601
Practice Address - Fax:773-435-4210
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist