Provider Demographics
NPI:1457411209
Name:KANG, SHIN W
Entity Type:Individual
Prefix:
First Name:SHIN
Middle Name:W
Last Name:KANG
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 1:2727 W OLYMPIC BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2640
Mailing Address - Country:US
Mailing Address - Phone:213-380-7077
Mailing Address - Fax:
Practice Address - Street 1:2727 W OLYMPIC BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2640
Practice Address - Country:US
Practice Address - Phone:213-380-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW15560207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A655771Medicaid
CAW15560Medicare PIN
CAX69220Medicare UPIN