Provider Demographics
NPI:1619114873
Name:SHINO, YUSAKU MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:YUSAKU
Middle Name:MICHAEL
Last Name:SHINO
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 1:1017 OCEAN AVE APT D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-3500
Mailing Address - Country:US
Mailing Address - Phone:310-866-6327
Mailing Address - Fax:
Practice Address - Street 1:6041 CADILLAC AVE
Practice Address - Street 2:KAISER WEST LOS ANGELES
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034
Practice Address - Country:US
Practice Address - Phone:888-505-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102464207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619114873OtherCCS PANELED PROVIDER
CA1619114873Medicaid
CABMY341YMedicare PIN