1275824971 NPI number — MARIE WONKYONG SHIN DPM

Table of content: MARIE WONKYONG SHIN DPM (NPI 1275824971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275824971 NPI number — MARIE WONKYONG SHIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIN
Provider First Name:
MARIE
Provider Middle Name:
WONKYONG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275824971
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2261 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33024-3623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-987-4991
Provider Business Mailing Address Fax Number:
954-987-4922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2261 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33024-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-987-4991
Provider Business Practice Location Address Fax Number:
954-987-4922
Provider Enumeration Date:
04/28/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  25MD00308000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: PO3564 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)