Provider Demographics
NPI:1316957202
Name:SHAW, MARY JO (MD)
Entity type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 155
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-667-0585
Mailing Address - Fax:208-667-0876
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 155
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-667-0585
Practice Address - Fax:208-667-0876
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM5325208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000163OtherREGENCE BLUE SHIELD
WA1040476Medicaid
ID000010000162OtherREGENCE BLUE SHIELD
MT1316957202Medicaid
IDDF474OtherBLUE CROSS OF IDAHO
ID000396600Medicaid
ID53256OtherBLUE CROSS OF IDAHO
IDC36989Medicare UPIN
WA1040476Medicaid