Provider Demographics
NPI:1104836352
Name:SHIM, MARK INBO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:INBO
Last Name:SHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IN BO
Other - Middle Name:
Other - Last Name:SHIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:237 82ND STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209
Mailing Address - Country:US
Mailing Address - Phone:718-836-0009
Mailing Address - Fax:718-836-1811
Practice Address - Street 1:237 82ND STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209
Practice Address - Country:US
Practice Address - Phone:718-836-0009
Practice Address - Fax:718-836-1811
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179695207RC0000X
NJ25MA05388000207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01273990Medicaid
W30751Medicare ID - Type Unspecified
E86399Medicare UPIN