Provider Demographics
NPI:1912264763
Name:CHIBA, SHINTARO (MD)
Entity Type:Individual
Prefix:
First Name:SHINTARO
Middle Name:
Last Name:CHIBA
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 1:2000 TRANS MOUNTAIN RD STE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-3602
Mailing Address - Country:US
Mailing Address - Phone:915-215-8000
Mailing Address - Fax:915-215-8674
Practice Address - Street 1:11175 CAMPUS STREET
Practice Address - Street 2:COLEMAN PAVILION 21111
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:347-446-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA153896208600000X
TXS3504208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery