Healthcare Provider Details

I. General information

NPI: 1366485948
Provider Name (Legal Business Name): GEORGE PAUL SHAW JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N MAIN ST
LA FAYETTE GA
30728-2241
US

IV. Provider business mailing address

611 N MAIN ST
LA FAYETTE GA
30728-2241
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5300
  • Fax: 706-638-5323
Mailing address:
  • Phone: 706-638-5300
  • Fax: 706-638-5323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number022056
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: