Provider Demographics
NPI:1851666341
Name:SHIN, EDWARD JAYWON (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JAYWON
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 1:436 RED WING DR
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-2710
Mailing Address - Country:US
Mailing Address - Phone:646-418-3015
Mailing Address - Fax:
Practice Address - Street 1:436 RED WING DR
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:CA
Practice Address - Zip Code:94507-2710
Practice Address - Country:US
Practice Address - Phone:646-418-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA177737207R00000X
NY245696-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine