Provider Demographics
NPI:1154949402
Name:SHAW, WALLACE PHILIP (BM BCH PHD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:PHILIP
Last Name:SHAW
Suffix:
Gender:M
Credentials:BM BCH PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 NEW HAMPSHIRE AVE NW APT 19
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-2545
Mailing Address - Country:US
Mailing Address - Phone:202-679-6003
Mailing Address - Fax:
Practice Address - Street 1:CLINICAL CENTER NIH
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-0001
Practice Address - Country:US
Practice Address - Phone:202-679-6003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD-484032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry