Provider Demographics
NPI:1912167461
Name:RUSS T SHIMIZU, M.D., INC.
Entity Type:Organization
Organization Name:RUSS T SHIMIZU, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHIMIZU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-829-5968
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 STE 550
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4806
Practice Address - Country:US
Practice Address - Phone:310-829-5968
Practice Address - Fax:310-453-3685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC333052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC33305OtherBLUE CROSS
CA00C333052OtherBLUE SHIELD
CAC33305Medicare PIN