Healthcare Provider Details

I. General information

NPI: 1386646867
Provider Name (Legal Business Name): STEVEN WAYNE NISHIBAYASHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

110 W STOCKER ST
GLENDALE CA
91202-2509
US

IV. Provider business mailing address

110 W STOCKER ST
GLENDALE CA
91202-2509
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-7237
  • Fax: 818-244-6787
Mailing address:
  • Phone: 818-244-7237
  • Fax: 818-244-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG38552
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: