Provider Demographics
NPI:1821041161
Name:ISHIMARU, MARK SHIGERU (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:SHIGERU
Last Name:ISHIMARU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:26730 CROWN VALLEY PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8001
Mailing Address - Country:US
Mailing Address - Phone:949-364-2154
Mailing Address - Fax:949-364-2110
Practice Address - Street 1:26730 CROWN VALLEY PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8001
Practice Address - Country:US
Practice Address - Phone:949-364-2154
Practice Address - Fax:949-364-2110
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG27381207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG27381Medicare ID - Type Unspecified
A43336Medicare UPIN