Healthcare Provider Details

I. General information

NPI: 1629399316
Provider Name (Legal Business Name): SHANA THEOBALD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 1ST ST STE A
SAN FRANCISCO CA
94105-2661
US

IV. Provider business mailing address

1606 9TH AVE
HONOLULU HI
96816-2804
US

V. Phone/Fax

Practice location:
  • Phone: 888-803-3370
  • Fax:
Mailing address:
  • Phone: 808-856-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number160381
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51568
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA11580200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number75194
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19456
License Number StateHI
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number204827
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7901
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: