Provider Demographics
NPI:1023547247
Name:SHIN, JAE WOOK (MD)
Entity type:Individual
Prefix:
First Name:JAE WOOK
Middle Name:
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 1:3833 DUNLAVY ST APT 243
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-4744
Mailing Address - Country:US
Mailing Address - Phone:310-940-9447
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN STREET, MSB 1.246
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-500-6590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-10
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV5346207RC0001X
390200000X
TXBP10082275207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program