Provider Demographics
NPI:1033670138
Name:ISHIBASHI, OLIVIA TAEKO (MD, MPH)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:TAEKO
Last Name:ISHIBASHI
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3414
Practice Address - Country:US
Practice Address - Phone:310-319-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA178419207Q00000X, 207QA0000X, 207QA0505X
390200000X
CAA178419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program