Provider Demographics
NPI:1821199068
Name:KIM, SHIN Y (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIN
Middle Name:Y
Last Name:KIM
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:PO BOX 21568
Mailing Address - Street 2:DEPT 284
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121
Mailing Address - Country:US
Mailing Address - Phone:800-915-3089
Mailing Address - Fax:
Practice Address - Street 1:645 N ARLINGTON AVE
Practice Address - Street 2:SUITE 250A
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4460
Practice Address - Country:US
Practice Address - Phone:775-329-7707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV97702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2016821Medicaid
NVG89996Medicare UPIN
NV35116Medicare ID - Type Unspecified
NVV35116Medicare PIN