Provider Demographics
NPI:1336542745
Name:DR BO SHIN, LLC
Entity Type:Organization
Organization Name:DR BO SHIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BO
Authorized Official - Middle Name:KYONG
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-825-8099
Mailing Address - Street 1:3113 CREST LN
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2229
Mailing Address - Country:US
Mailing Address - Phone:201-705-7885
Mailing Address - Fax:888-866-7055
Practice Address - Street 1:7 BROAD AVE STE 203
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1886
Practice Address - Country:US
Practice Address - Phone:201-705-7885
Practice Address - Fax:888-866-7055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00308100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty