Healthcare Provider Details

I. General information

NPI: 1518013317
Provider Name (Legal Business Name): SHAWN BARTON HERSEVOORT M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 02/09/2022
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 TELEGRAPH AVE STE 515
BERKELEY CA
94705-1151
US

IV. Provider business mailing address

2855 TELEGRAPH AVE STE 515
BERKELEY CA
94705-1151
US

V. Phone/Fax

Practice location:
  • Phone: 877-768-7075
  • Fax:
Mailing address:
  • Phone: 877-768-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA88489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: