Healthcare Provider Details

I. General information

NPI: 1528387438
Provider Name (Legal Business Name): JUSTIN M SHAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 ROYER DRIVE SUITE 103
LANCASTER PA
17601-5102
US

IV. Provider business mailing address

485 ROYER DRIVE SUITE 103
LANCASTER PA
17601-5102
US

V. Phone/Fax

Practice location:
  • Phone: 717-560-4020
  • Fax: 717-560-2919
Mailing address:
  • Phone: 717-560-4020
  • Fax: 717-560-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD454562
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD454562
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: