Provider Demographics
NPI:1538194675
Name:SHAW, TARA A (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:A
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 1:275 W MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5641
Mailing Address - Country:US
Mailing Address - Phone:510-752-1000
Mailing Address - Fax:707-651-2743
Practice Address - Street 1:275 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5641
Practice Address - Country:US
Practice Address - Phone:510-752-1000
Practice Address - Fax:707-651-2743
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113299207Q00000X
CAA80836207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I22163Medicare UPIN