MEDICARE: GAIL SUMIKO SHIBATA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP3000X	Pediatric Anesthesiology Physician	G79502	CA
2	207L00000X	Anesthesiology Physician	G79502	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G795020	OTHER	CA	BLUE SHIELD OF CA
2	00G795020303	OTHER	CA	CALOPTIMA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902841869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL SUMIKO SHIBATA MD

Provider Business Mailing Address
First Line	:	FILE 4501
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-0001
Country	:	US
Telephone Number	:	503-372-2740
Fax Number	:	503-372-2754

Provider Business Practice Location Address
First Line	:	1975 4TH ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94143-2351
Country	:	US
Telephone Number	:	415-885-7268
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	04/02/2019

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