Provider Demographics
NPI:1407140056
Name:SHUM, JOHNNY Y (DO)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:Y
Last Name:SHUM
Suffix:
Gender:M
Credentials:DO
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:4540 UNION BAY PL NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4025
Practice Address - Country:US
Practice Address - Phone:206-320-3400
Practice Address - Fax:206-320-5773
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60384423208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1407140056Medicaid
WA2020728Medicaid
WAG8930498OtherMEDICARE W VALLEY MEDICAL GROUP - RENTON