Provider Demographics
NPI:1689954695
Name:SHIBAYAMA, VIVIAN PHAN (OD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:PHAN
Last Name:SHIBAYAMA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6290 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1614
Mailing Address - Country:US
Mailing Address - Phone:626-274-4211
Mailing Address - Fax:
Practice Address - Street 1:100 STEIN PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-7065
Practice Address - Country:US
Practice Address - Phone:310-825-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14290152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFL508ZMedicare PIN