Provider Demographics
NPI:1376789826
Name:SHIN, JEOUNG GYU (LMT)
Entity Type:Individual
Prefix:MR
First Name:JEOUNG
Middle Name:GYU
Last Name:SHIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 EAST GRAND RESERVE CIRCLE
Mailing Address - Street 2:#1437
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759
Mailing Address - Country:US
Mailing Address - Phone:727-729-2967
Mailing Address - Fax:
Practice Address - Street 1:2707 E GRAND RESERVE CIR
Practice Address - Street 2:#1437
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-4919
Practice Address - Country:US
Practice Address - Phone:727-729-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46774174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist