Provider Demographics
NPI:1871544536
Name:SHAW, DOMINIQUE M (MD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7717B 247TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1830
Mailing Address - Country:US
Mailing Address - Phone:310-600-8263
Mailing Address - Fax:
Practice Address - Street 1:264 W 118TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1620
Practice Address - Country:US
Practice Address - Phone:212-932-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87149207V00000X
NY282753207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ51655OtherMEDICAL LICENSE NUMBER
CAA87149OtherMEDICAL LICENSE NUMBER
NY282753OtherMEDICAL LICENSE NUMBER