Healthcare Provider Details

I. General information

NPI: 1619114873
Provider Name (Legal Business Name): YUSAKU MICHAEL SHINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 CADILLAC AVE KAISER WEST LOS ANGELES
LOS ANGELES CA
90034
US

IV. Provider business mailing address

1017 OCEAN AVE APT D
SANTA MONICA CA
90403-3500
US

V. Phone/Fax

Practice location:
  • Phone: 888-505-0043
  • Fax:
Mailing address:
  • Phone: 310-866-6327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA102464
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA102464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: