Provider Demographics
NPI:1548307275
Name:SHAW, DAVID DOUGLAS (CPO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:DOUGLAS
Last Name:SHAW
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:D.
Other - Middle Name:DOUGLAS
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPO
Mailing Address - Street 1:312 COMMERCE ST
Mailing Address - Street 2:UNIT 10
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7832
Mailing Address - Country:US
Mailing Address - Phone:802-864-9909
Mailing Address - Fax:
Practice Address - Street 1:312 COMMERCE ST
Practice Address - Street 2:UNIT 10
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7832
Practice Address - Country:US
Practice Address - Phone:802-864-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009187Medicaid
NY01060791Medicaid
VT054 2771OtherBLUE CROSS BLUE SHIELD
VT0413140001Medicare NSC