Provider Demographics
NPI:1457442154
Name:SHIN, DUSIK K (MD)
Entity Type:Individual
Prefix:
First Name:DUSIK
Middle Name:K
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:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40602-5007
Mailing Address - Country:US
Mailing Address - Phone:502-226-3858
Mailing Address - Fax:502-223-9829
Practice Address - Street 1:1107 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1169
Practice Address - Country:US
Practice Address - Phone:502-226-3858
Practice Address - Fax:502-223-9829
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY166422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64266424Medicaid
KYC74357OtherBLUEGRASS FAMILY HEALTH
KY000000111566OtherANTHEM BLUE CROSS
KY1600202OtherUNITED HEALTHCARE
KY1326601Medicare ID - Type Unspecified
KYC74357OtherBLUEGRASS FAMILY HEALTH