Provider Demographics
NPI:1932103843
Name:WITHERS, JUNE SHAO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNE
Middle Name:SHAO
Last Name:WITHERS
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 1:4966 EL CAMINO REAL STE 111
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1406
Mailing Address - Country:US
Mailing Address - Phone:650-968-2389
Mailing Address - Fax:
Practice Address - Street 1:4966 EL CAMINO REAL STE 111
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1406
Practice Address - Country:US
Practice Address - Phone:650-224-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72572208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A725720Medicaid
CA00A725720Medicaid
CA00A725721Medicare ID - Type Unspecified