Healthcare Provider Details

I. General information

NPI: 1679708697
Provider Name (Legal Business Name): DANIEL SHIBRU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 OAK GROVE ST APT 211
MINNEAPOLIS MN
55403-4004
US

IV. Provider business mailing address

1524 WOOLSEY ST APT A
BERKELEY CA
94703-2368
US

V. Phone/Fax

Practice location:
  • Phone: 510-282-9145
  • Fax:
Mailing address:
  • Phone: 510-282-9145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA85654
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA85654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: