Provider Demographics
NPI:1396865788
Name:SHAW, JESSE (DO)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:MR
Other - First Name:JESSE
Other - Middle Name:ZISHOLTZ
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:17779 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3924
Mailing Address - Country:US
Mailing Address - Phone:954-450-0099
Mailing Address - Fax:954-450-0022
Practice Address - Street 1:17779 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3924
Practice Address - Country:US
Practice Address - Phone:954-450-0099
Practice Address - Fax:954-450-0022
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10003207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278697400Medicaid
FL278697400Medicaid