Provider Demographics
NPI:1679504302
Name:SHIM, YEON A (DPM)
Entity Type:Individual
Prefix:
First Name:YEON
Middle Name:A
Last Name:SHIM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 E 3RD AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-1697
Mailing Address - Country:US
Mailing Address - Phone:908-620-3200
Mailing Address - Fax:908-620-1040
Practice Address - Street 1:1305 SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-2806
Practice Address - Country:US
Practice Address - Phone:908-620-3200
Practice Address - Fax:908-620-1040
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002426213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU69100Medicare UPIN
NJ006323Medicare ID - Type Unspecified