Provider Demographics
NPI:1023317286
Name:SHIN, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
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 1:5965 VILLAGE WAY
Mailing Address - Street 2:SUITE E105, UNIT 244
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130
Mailing Address - Country:US
Mailing Address - Phone:619-786-4128
Mailing Address - Fax:
Practice Address - Street 1:320 SANTA FE DR STE 107-C
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5138
Practice Address - Country:US
Practice Address - Phone:760-230-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-26
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA130231207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine