MEDICARE: DAVID LEE SHAW MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	ME23236	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17403	OTHER	FL	BCBS FL
2	17403	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1073506432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID LEE SHAW MD

Provider Business Mailing Address
First Line	:	907 MAR WALT DRIVE
Second Line	:	SUITE 2021
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6960
Country	:	US
Telephone Number	:	850-863-0006
Fax Number	:	850-863-0012

Provider Business Practice Location Address
First Line	:	907 MAR WALT DRIVE
Second Line	:	SUITE 2021
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6960
Country	:	US
Telephone Number	:	850-863-0006
Fax Number	:	850-863-0012

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	11/28/2011

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Directions to “ DAVID LEE SHAW MD” Practice Location

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