Provider Demographics
NPI:1881641892
Name:SHIN, SOOK-JA (MD)
Entity Type:Individual
Prefix:DR
First Name:SOOK-JA
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 EL NITA LN
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-4603
Mailing Address - Country:US
Mailing Address - Phone:951-929-6260
Mailing Address - Fax:951-765-2855
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:909-806-1017
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37091207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A370910Medicaid
CAA37091AMedicare PIN
CAWA37091AMedicare PIN
CABH039ZMedicare PIN
CAB18505Medicare UPIN