Provider Demographics
NPI:1245407295
Name:JOHN, SHINE (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHINE
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11614 FM 2244 RD STE 150
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5471
Mailing Address - Country:US
Mailing Address - Phone:512-399-5711
Mailing Address - Fax:512-399-5707
Practice Address - Street 1:11614 FM 2244 RD STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-5471
Practice Address - Country:US
Practice Address - Phone:512-399-5711
Practice Address - Fax:512-399-5707
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005365213E00000X
TX1910213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005365OtherIL STATE LICENSE
TX1910OtherSTATE OF TEXAS