Healthcare Provider Details

I. General information

NPI: 1689954695
Provider Name (Legal Business Name): VIVIAN PHAN SHIBAYAMA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STEIN PLAZA SUITE 2-525
LOS ANGELES CA
90095-7065
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number14290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: