Provider Demographics
NPI:1720020647
Name:SHINA, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SHINA
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 1:415 HOSPITAL DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701-4651
Mailing Address - Country:US
Mailing Address - Phone:870-837-2888
Mailing Address - Fax:870-837-2892
Practice Address - Street 1:415 HOSPITAL DR STE 3
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701
Practice Address - Country:US
Practice Address - Phone:870-837-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23428208600000X
ARE-11636208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100020000AMedicaid
KY64234289Medicaid
C76586Medicare UPIN
KY1561301Medicare ID - Type Unspecified
IN100020000AMedicaid