Provider Demographics
NPI:1609526490
Name:SHIN, SIMON (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
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 1:9230 BURT ST APT 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2468
Mailing Address - Country:US
Mailing Address - Phone:206-920-7917
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVENUE BOX SURG
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:206-920-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program