Healthcare Provider Details

I. General information

NPI: 1770900821
Provider Name (Legal Business Name): MANESSA CRYSTAL SHAW DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11333 SEPULVEDA BLVD
MISSION HILLS CA
91345-1116
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 818-365-9531
  • Fax: 818-837-5559
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A14739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: