Provider Demographics
NPI:1275824971
Name:SHIN, MARIE WONKYONG (DPM)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:WONKYONG
Last Name:SHIN
Suffix:
Gender:F
Credentials:DPM
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Mailing Address - Street 1:12665 GARDEN GROVE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1916
Mailing Address - Country:US
Mailing Address - Phone:714-620-4699
Mailing Address - Fax:888-866-7055
Practice Address - Street 1:12665 GARDEN GROVE BLVD STE 203
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1916
Practice Address - Country:US
Practice Address - Phone:714-620-4699
Practice Address - Fax:888-866-7055
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA5711213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery