Provider Demographics
NPI:1760147540
Name:SHIN, SOOHWAN (DPT)
Entity Type:Individual
Prefix:
First Name:SOOHWAN
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 OLANDWOOD CT STE 110
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1373
Mailing Address - Country:US
Mailing Address - Phone:301-774-0500
Mailing Address - Fax:301-774-7338
Practice Address - Street 1:3416 OLANDWOOD CT STE 110
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1373
Practice Address - Country:US
Practice Address - Phone:301-774-0500
Practice Address - Fax:301-774-7338
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD28658OtherMD LICENSE