Healthcare Provider Details

I. General information

NPI: 1073587382
Provider Name (Legal Business Name): SAM REED SHIMAMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 E BASELINE RD SUITE 112
GILBERT AZ
85234-2965
US

IV. Provider business mailing address

4915 E BASELINE RD STE 112
GILBERT AZ
85234-2966
US

V. Phone/Fax

Practice location:
  • Phone: 480-626-6600
  • Fax: 480-626-6604
Mailing address:
  • Phone: 480-626-6600
  • Fax: 480-626-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number29558
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: