MEDICARE: WHITNEY 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	OPT.6502	OH

General Provider Information

NPI Number	:	1356790414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WHITNEY SHAW O.D.

Provider Business Mailing Address
First Line	:	118 CASS AVE
Second Line	:
City	:	MOUNT CLEMENS
State	:	MI
Zip	:	48043-2204
Country	:	US
Telephone Number	:	586-464-1479
Fax Number	:	586-464-1480

Provider Business Practice Location Address
First Line	:	6835 PEARL RD
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-3616
Country	:	US
Telephone Number	:	440-884-4725
Fax Number	:	440-884-4752

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

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	02/21/2018

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