Healthcare Provider Details

I. General information

NPI: 1376537753
Provider Name (Legal Business Name): RICHARD MARK SHAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 ALAMO ST #100
SIMI VALLEY CA
93065-1311
US

IV. Provider business mailing address

2755 ALAMO ST STE 201
SIMI VALLEY CA
93063-1346
US

V. Phone/Fax

Practice location:
  • Phone: 805-210-7280
  • Fax:
Mailing address:
  • Phone: 805-210-7280
  • Fax: 805-210-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG75294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: