Provider Demographics
NPI:1346904828
Name:SHIMABUKURO, CODY (DPT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:SHIMABUKURO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8545 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3868
Mailing Address - Country:US
Mailing Address - Phone:909-365-3557
Mailing Address - Fax:909-658-8987
Practice Address - Street 1:8545 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3868
Practice Address - Country:US
Practice Address - Phone:909-365-3557
Practice Address - Fax:909-658-8987
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist