Provider Demographics
NPI:1083754261
Name:SHIN, PETER E (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:SHIN
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 1:416 E BROADWAY
Mailing Address - Street 2:#311
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1047
Mailing Address - Country:US
Mailing Address - Phone:818-396-4383
Mailing Address - Fax:818-396-4383
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:EMERGENCY DEPT. - GLENDALE ADVENTIST MEDICAL CENTER
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106933207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services