Provider Demographics
NPI:1417169376
Name:SHIN, TAEK SOO (MD)
Entity Type:Individual
Prefix:
First Name:TAEK SOO
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 1:2601 LITTLE ELM PKWY STE 1404
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-1922
Mailing Address - Country:US
Mailing Address - Phone:972-972-4234
Mailing Address - Fax:972-777-1090
Practice Address - Street 1:2601 LITTLE ELM PKWY STE 1404
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-1922
Practice Address - Country:US
Practice Address - Phone:972-972-4234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116597207R00000X
IL036116597208M00000X
TXS5269207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00855816OtherRR MEDICARE PTAN
IL036116597Medicaid
IL215188002Medicare PIN