Provider Demographics
NPI:1396019303
Name:SHIBATA, OWEN (MD)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:SHIBATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6814
Mailing Address - Country:US
Mailing Address - Phone:925-399-5422
Mailing Address - Fax:
Practice Address - Street 1:2100 EMBARCADERO
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-5302
Practice Address - Country:US
Practice Address - Phone:800-268-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66533208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice