Provider Demographics
NPI:1578570958
Name:SHIBATA, DARRYL KENJI (MD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:KENJI
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:323-442-2588
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5331
Practice Address - Country:US
Practice Address - Phone:323-442-2582
Practice Address - Fax:323-442-2588
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54288207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA220012798OtherMEDICARE RAILROAD
CA00G542880OtherBLUE SHIELD
CA00G542880Medicaid
CA1952325565OtherGROUP NPI
CAHW7801AMedicare PIN
CAWG54288BMedicare PIN
CA220012798OtherMEDICARE RAILROAD
CA00G542880Medicaid
CAHW7801BMedicare PIN