Provider Demographics
NPI:1952362600
Name:SHIN, SOO YOUNG (MD)
Entity Type:Individual
Prefix:
First Name:SOO YOUNG
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SOO
Other - Middle Name:YOUNG
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:19441 GOLF VISTA PLAZA
Mailing Address - Street 2:SUITE 320
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:703-858-9800
Mailing Address - Fax:
Practice Address - Street 1:19441 GOLF VISTA PLAZA
Practice Address - Street 2:SUITE 320
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-858-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226980207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006303633Medicaid
DCG00396Medicare UPIN
VAC05409Medicare UPIN
DC017822V96Medicare PIN
VA18000924Medicare PIN