Healthcare Provider Details

I. General information

NPI: 1437403763
Provider Name (Legal Business Name): JOHN M SHIMA MD PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W E ST
FORKS WA
98331-9121
US

IV. Provider business mailing address

460 W E ST
FORKS WA
98331-9121
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00019175
License Number StateWA

VIII. Authorized Official

Name: DR. JOHN M SHIMA
Title or Position: PRESIDENT
Credential: MD
Phone: 360-374-2500