Provider Demographics
NPI:1275824971
Name:SHIN, MARIE WONKYONG (DPM)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:WONKYONG
Last Name:SHIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2261 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3623
Mailing Address - Country:US
Mailing Address - Phone:954-987-4991
Mailing Address - Fax:954-987-4922
Practice Address - Street 1:2261 N UNIVERSITY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3623
Practice Address - Country:US
Practice Address - Phone:954-987-4991
Practice Address - Fax:954-987-4922
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MD00308000213EP1101X
FLPO3564213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery