Provider Demographics
NPI:1780775379
Name:SHIN, HENRY JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JOHN
Last Name:SHIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7249 CALABRIA CT UNIT 62
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-6002
Mailing Address - Country:US
Mailing Address - Phone:619-475-3338
Mailing Address - Fax:619-267-7977
Practice Address - Street 1:2340 E 8TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2869
Practice Address - Country:US
Practice Address - Phone:619-475-3338
Practice Address - Fax:619-267-7977
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4180213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41800Medicaid
CAU73571Medicare UPIN
CA000E41800Medicaid