Provider Demographics
NPI:1194899831
Name:SHIGEMATSU, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:SHIGEMATSU
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 1:420 EAST THIRD ST
Mailing Address - Street 2:SUITE 705
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013
Mailing Address - Country:US
Mailing Address - Phone:213-628-1020
Mailing Address - Fax:213-628-8780
Practice Address - Street 1:420 EAST THIRD ST
Practice Address - Street 2:SUITE 705
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:213-628-1020
Practice Address - Fax:213-628-8780
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0045240Medicaid
A51946Medicare UPIN
W11062Medicare ID - Type Unspecified