Provider Demographics
NPI:1013636190
Name:SHIN, DONG JOO
Entity Type:Individual
Prefix:
First Name:DONG JOO
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10560 LAKESIDE DR N UNIT D
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5058
Mailing Address - Country:US
Mailing Address - Phone:949-331-4540
Mailing Address - Fax:
Practice Address - Street 1:9884 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1643
Practice Address - Country:US
Practice Address - Phone:714-822-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19455171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty