Provider Demographics
NPI:1184794349
Name:SHIN, SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 MEDICAL DR
Mailing Address - Street 2:STE D
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8704
Mailing Address - Country:US
Mailing Address - Phone:575-434-2229
Mailing Address - Fax:575-439-5705
Practice Address - Street 1:FORT DEFIANCE PHS HOSPITAL
Practice Address - Street 2:CORNER OF ROUTE N12 & N7
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2192-18207V00000X
AZ3715207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ640921Medicaid
NM54834864Medicaid
AZH56161Medicare UPIN
NM54834864Medicaid