Provider Demographics
NPI:1316930183
Name:SHAW, TIMOTHY SHANE (MD, PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SHANE
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 OGLETREE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-9226
Mailing Address - Country:US
Mailing Address - Phone:936-328-8080
Mailing Address - Fax:936-328-8505
Practice Address - Street 1:601 OGELTREE DR.
Practice Address - Street 2:SUITE D
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351
Practice Address - Country:US
Practice Address - Phone:936-328-8080
Practice Address - Fax:936-328-8505
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1343174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1788538Medicaid
TXP00256091OtherMEDICARE RAILROAD
LA1788538Medicaid
TX8F1111Medicare PIN