Provider Demographics
NPI:1780688242
Name:SHIMIZU, RUSS T (MD)
Entity type:Individual
Prefix:DR
First Name:RUSS
Middle Name:T
Last Name:SHIMIZU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 WILSHIRE BLVD STE 550
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4806
Mailing Address - Country:US
Mailing Address - Phone:310-323-0026
Mailing Address - Fax:310-453-3685
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:STE 790
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4805
Practice Address - Country:US
Practice Address - Phone:310-829-5968
Practice Address - Fax:310-453-3685
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-11
Last Update Date:2021-02-11
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
CAC333052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC33305Medicare ID - Type UnspecifiedLICENSE