Provider Demographics
NPI:1750388633
Name:KANEKO, SHINOBU LUISA (MD)
Entity type:Individual
Prefix:DR
First Name:SHINOBU
Middle Name:LUISA
Last Name:KANEKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-0129
Mailing Address - Country:US
Mailing Address - Phone:626-458-1201
Mailing Address - Fax:626-458-3736
Practice Address - Street 1:823 S ATLANTIC BLVD STE 4
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4721
Practice Address - Country:US
Practice Address - Phone:626-458-1201
Practice Address - Fax:626-458-3736
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA80720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A807200Medicaid
CAW18377Medicare Oscar/Certification
CAI13066Medicare UPIN
CA00A807200Medicaid