Provider Demographics
NPI:1275065518
Name:SHIBATA, RENAE (MD)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:SHIBATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 COLUMBIA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1133
Mailing Address - Country:US
Mailing Address - Phone:321-841-6060
Mailing Address - Fax:321-841-2442
Practice Address - Street 1:21 COLUMBIA ST STE 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1133
Practice Address - Country:US
Practice Address - Phone:321-841-6060
Practice Address - Fax:321-841-2442
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309052-01207V00000X
390200000X
FLME163067207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119187100Medicaid