Provider Demographics
NPI:1871568170
Name:SHIMABUKURO, LYNN M (MD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:M
Last Name:SHIMABUKURO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2859 VIRGINIA BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:757-340-4901
Mailing Address - Fax:757-340-2502
Practice Address - Street 1:2859 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452
Practice Address - Country:US
Practice Address - Phone:757-340-4901
Practice Address - Fax:757-340-2502
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005836069Medicaid
VA005836069Medicaid
110004249Medicare ID - Type Unspecified