Provider Demographics
NPI:1528079282
Name:SHIBATA, KENNETH H (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:SHIBATA
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 1:1608 S J ST
Mailing Address - Street 2:FLOOR 3
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7503
Mailing Address - Fax:253-274-7993
Practice Address - Street 1:1608 S J ST
Practice Address - Street 2:FLOOR 3
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4930
Practice Address - Country:US
Practice Address - Phone:253-274-7503
Practice Address - Fax:253-274-7993
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8243388Medicaid
WA0223687OtherL & I
WA8933459OtherCRIME VICTIMS
WA110248736OtherRAILROAD
WA167254OtherL & I
WAG8867034Medicare PIN
WAG8925565Medicare PIN
WA110248736OtherRAILROAD
WA8243388Medicaid
WAGAB35237Medicare PIN