Provider Demographics
NPI:1851352330
Name:SHIMODA, MAKO (MD)
Entity Type:Individual
Prefix:
First Name:MAKO
Middle Name:
Last Name:SHIMODA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 ARAPAHOE AVENUE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303
Mailing Address - Country:US
Mailing Address - Phone:303-441-0587
Mailing Address - Fax:303-996-0801
Practice Address - Street 1:4745 ARAPAHOE AVENUE
Practice Address - Street 2:SUITE 320
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303
Practice Address - Country:US
Practice Address - Phone:303-441-0587
Practice Address - Fax:303-996-0801
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36257207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55404251Medicaid
G11843Medicare UPIN
CO55404251Medicaid
CO55404251Medicare PIN