Provider Demographics
NPI:1740387646
Name:SHIN, DONG W (MD)
Entity Type:Individual
Prefix:
First Name:DONG
Middle Name:W
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 1:3030 W OLYMPIC BLVD
Mailing Address - Street 2:206
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6501
Mailing Address - Country:US
Mailing Address - Phone:213-738-7788
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD
Practice Address - Street 2:206
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6501
Practice Address - Country:US
Practice Address - Phone:213-738-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG066054207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF61175Medicare UPIN