Provider Demographics
NPI:1720005259
Name:SHIN, MIN SOO (MD,APC)
Entity Type:Individual
Prefix:
First Name:MIN
Middle Name:SOO
Last Name:SHIN
Suffix:
Gender:M
Credentials:MD,APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2968 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255
Mailing Address - Country:US
Mailing Address - Phone:323-583-1500
Mailing Address - Fax:323-583-1661
Practice Address - Street 1:2968 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255
Practice Address - Country:US
Practice Address - Phone:323-583-1500
Practice Address - Fax:323-583-1661
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40822207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A408220Medicaid
CA27-4412313OtherTAX ID
CA27-4412313OtherTAX ID
CA00A408220Medicaid