Provider Demographics
NPI:1114920477
Name:SHIN, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:901 E ST
Mailing Address - Street 2:STE 285
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2850
Mailing Address - Country:US
Mailing Address - Phone:415-454-5565
Mailing Address - Fax:415-454-2957
Practice Address - Street 1:901 E ST
Practice Address - Street 2:STE 285
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2850
Practice Address - Country:US
Practice Address - Phone:415-454-5565
Practice Address - Fax:415-454-2957
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0015750Medicaid
CAGR0015750Medicaid
CAZZZ91585ZMedicare ID - Type Unspecified