=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265528665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LACY B SHAW O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 08/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5615-B JACKSON ST EXT
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-442-7787
-----------------------------------------------------
Fax | 318-443-1654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5615-B JACKSON ST EXT
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-442-7787
-----------------------------------------------------
Fax | 318-443-1654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 734-081T
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 734-081T
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------