Provider Demographics
NPI:1598724114
Name:SHINE, KIMBERLEY IRENE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:IRENE
Last Name:SHINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:960 E GREEN ST
Mailing Address - Street 2:STE 206
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2401
Mailing Address - Country:US
Mailing Address - Phone:626-317-0207
Mailing Address - Fax:626-317-0250
Practice Address - Street 1:960 E GREEN ST STE 206
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2401
Practice Address - Country:US
Practice Address - Phone:626-307-0207
Practice Address - Fax:626-317-0195
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH96873Medicare UPIN