Provider Demographics
NPI:1164075198
Name:SHIN, DONG EOK
Entity Type:Individual
Prefix:
First Name:DONG EOK
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23684 GOLD NUGGET AVE
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2335
Mailing Address - Country:US
Mailing Address - Phone:213-500-8292
Mailing Address - Fax:
Practice Address - Street 1:4250 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-2602
Practice Address - Country:US
Practice Address - Phone:909-964-9524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70820156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA70820OtherRDO