Provider Demographics
NPI:1184735920
Name:SHIMAHARA, LILLY (DPM)
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:SHIMAHARA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12033 AGENCY RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-7718
Mailing Address - Country:US
Mailing Address - Phone:928-669-2137
Mailing Address - Fax:
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3769213E00000X
GUPOD3213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0201750OtherBC/BS OF ARIZONA
AZ520131Medicaid
AZ216220Medicaid
AZ020537Medicaid
AZ216220Medicaid
03130ZMedicare Oscar/Certification
AZ020537Medicaid
8HP192Medicare PIN
U43632Medicare UPIN