Healthcare Provider Details

I. General information

NPI: 1710160726
Provider Name (Legal Business Name): ROBERT JAMES SHAW LDO, CPOT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13504 NE 84TH ST # 103255
VANCOUVER WA
98682-3091
US

IV. Provider business mailing address

13504 NE 84TH ST # 103255
VANCOUVER WA
98682-3091
US

V. Phone/Fax

Practice location:
  • Phone: 509-969-3308
  • Fax:
Mailing address:
  • Phone: 509-969-3308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO00002080
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: