Healthcare Provider Details

I. General information

NPI: 1912293572
Provider Name (Legal Business Name): JESSE DANIEL SHAW D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 ATHLETICS CENTER
STILLWATER OK
74078-0001
US

IV. Provider business mailing address

5310 E 31ST ST STE 13
TULSA OK
74135-5013
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-5430
  • Fax:
Mailing address:
  • Phone: 918-561-5701
  • Fax: 918-561-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number9600
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: