Provider Demographics
NPI:1215952569
Name:SHAW, TRISTY S (MD)
Entity type:Individual
Prefix:DR
First Name:TRISTY
Middle Name:S
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:520 N PROSPECT AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3041
Mailing Address - Country:US
Mailing Address - Phone:310-406-2349
Mailing Address - Fax:310-406-8012
Practice Address - Street 1:520 N PROSPECT AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-406-2349
Practice Address - Fax:310-406-8012
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA055884208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics