Basic Information
| Provider Information | |||||||||
| NPI: | 1619114873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHINO | ||||||||
| FirstName: | YUSAKU | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1017 OCEAN AVE APT D | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904033500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108666327 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6041 CADILLAC AVE | ||||||||
| Address2: | KAISER WEST LOS ANGELES | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885050043 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2009 | ||||||||
| LastUpdateDate: | 01/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A102464 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | A102464 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 1619114873 | 01 | CA | CCS PANELED PROVIDER | OTHER | 1619114873 | 05 | CA | MEDICAID |