Provider Demographics
NPI:1760411169
Name:SHIN, JIYEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JIYEN
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W VALLEY BLVD
Mailing Address - Street 2:#115
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3760
Mailing Address - Country:US
Mailing Address - Phone:626-288-8023
Mailing Address - Fax:626-288-8326
Practice Address - Street 1:140 W VALLEY BLVD
Practice Address - Street 2:#115
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3760
Practice Address - Country:US
Practice Address - Phone:626-288-8023
Practice Address - Fax:626-288-8326
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB237190OtherMEDICARE PTAN
CASD0097270Medicaid
CACB237189OtherMEDICARE PTAN
CASD0097270Medicaid