Provider Demographics
NPI:1982628756
Name:SHIN, ANTHONY S (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:S
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:PO BOX 946
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0946
Mailing Address - Country:US
Mailing Address - Phone:951-273-0136
Mailing Address - Fax:951-848-9121
Practice Address - Street 1:12000 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5174
Practice Address - Country:US
Practice Address - Phone:951-273-0136
Practice Address - Fax:951-848-9121
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA426012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A426010Medicaid
CA00A426010Medicaid
CA00A426010Medicare ID - Type UnspecifiedMEDICARE