Healthcare Provider Details

I. General information

NPI: 1174443725
Provider Name (Legal Business Name): QUENTIN SHAW OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 N RIDGE RD
WICHITA KS
67205-1203
US

IV. Provider business mailing address

12106 W AUTUMN RIDGE CT
WICHITA KS
67235-9725
US

V. Phone/Fax

Practice location:
  • Phone: 316-201-4600
  • Fax:
Mailing address:
  • Phone: 785-829-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2282
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: