Healthcare Provider Details

I. General information

NPI: 1114487170
Provider Name (Legal Business Name): ANDREW DAVID SHAW DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BARRETT DR STE 100
WEBSTER NY
14580-4516
US

IV. Provider business mailing address

55 BARRETT DR STE 100
WEBSTER NY
14580-4516
US

V. Phone/Fax

Practice location:
  • Phone: 585-758-0750
  • Fax:
Mailing address:
  • Phone: 585-758-0750
  • Fax: 585-872-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number318798
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number318798
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number318798
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: