Provider Demographics
NPI:1154302107
Name:LIN, SHINE SHONG (MD)
Entity Type:Individual
Prefix:DR
First Name:SHINE
Middle Name:SHONG
Last Name:LIN
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 1:10121 ANNIE ST
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-4355
Mailing Address - Country:US
Mailing Address - Phone:916-226-1931
Mailing Address - Fax:
Practice Address - Street 1:10121 ANNIE ST
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-4355
Practice Address - Country:US
Practice Address - Phone:916-226-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36533208600000X
ARR-3537208600000X
MI4301034994208600000X
MO2009001610208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166502001Medicaid
AR166502001Medicaid