=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740472794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGER F SHAW III A PROFESSIONAL OPTOMETRY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23855 EDEN ST
-----------------------------------------------------
City | PLAQUEMINE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70764-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-687-2026
-----------------------------------------------------
Fax | 225-687-2000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23855 EDEN ST
-----------------------------------------------------
City | PLAQUEMINE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70764-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-687-2026
-----------------------------------------------------
Fax | 225-687-2000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | DR. ANN HARDIN SHAW
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 225-687-2026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 754-055T
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------