Provider Demographics
NPI:1467507863
Name:SHIN, LEWIS KIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:KIE
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 1:2940 E. BANNER GATEWAY DRIVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-3430
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:BANNER MD ANDERSON CANCER CENTER
Practice Address - Street 2:2946 E BANNER GATEWAY DRIVE
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-3682
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA895142085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A895140Medicaid
CAI29449Medicare UPIN
CA00A895140Medicaid