MEDICARE: DR. JACOB D SHAW O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1665	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8141	OTHER	KS	PPK
4	267621	OTHER	KS	COVENTRY-LOC#2
5	269147	OTHER	KS	COVENTRY-LOC#1

General Provider Information

NPI Number	:	1093793713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB D SHAW O.D.

Provider Business Mailing Address
First Line	:	2251 N WOODLAWN ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-3947
Country	:	US
Telephone Number	:	316-686-6063
Fax Number	:	316-686-4214

Provider Business Practice Location Address
First Line	:	2251 N WOODLAWN ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-3947
Country	:	US
Telephone Number	:	316-686-6063
Fax Number	:	316-686-4214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	11/21/2007

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