Provider Demographics
NPI:1760135636
Name:JAE YOON SHIN DPM P.C.
Entity Type:Organization
Organization Name:JAE YOON SHIN DPM P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAE
Authorized Official - Middle Name:YOON
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:267-269-7127
Mailing Address - Street 1:4220 27TH ST APT 515
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-8618
Mailing Address - Country:US
Mailing Address - Phone:267-268-7127
Mailing Address - Fax:
Practice Address - Street 1:283 LEONARD PL
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-4517
Practice Address - Country:US
Practice Address - Phone:267-269-7127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPOD001311OtherPODIATRIC LICENSE
NJ25MD00365800OtherPODIATRIC LICENSE
NYN007210-01OtherPODIATRIC LICENSE