Healthcare Provider Details

I. General information

NPI: 1790984276
Provider Name (Legal Business Name): MANON BROOKE MASHBURN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 BRODER BLVD
DUBLIN CA
94568-3309
US

IV. Provider business mailing address

3183 LANSDOWN CT
PLEASANTON CA
94588-3527
US

V. Phone/Fax

Practice location:
  • Phone: 925-551-6740
  • Fax:
Mailing address:
  • Phone: 45-975-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD.200800
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200800
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC-172128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: