Provider Demographics
NPI:1154609766
Name:SHAW, GREGORY A (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
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:PO BOX 492080
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-2080
Mailing Address - Country:US
Mailing Address - Phone:530-243-1236
Mailing Address - Fax:530-245-5949
Practice Address - Street 1:2020 COURT ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1822
Practice Address - Country:US
Practice Address - Phone:530-243-1236
Practice Address - Fax:530-245-5949
Is Sole Proprietor?:No
Enumeration Date:2011-07-30
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY504762085R0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program