Provider Demographics
NPI:1275554057
Name:SHIN, ELLIOT (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-243-8500
Mailing Address - Fax:702-258-6152
Practice Address - Street 1:888 S RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3810
Practice Address - Country:US
Practice Address - Phone:702-243-8500
Practice Address - Fax:702-258-6152
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12070207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1275554057Medicaid
NV100510966Medicaid
NV100510966Medicaid
NVFN542ZMedicare PIN