Healthcare Provider Details

I. General information

NPI: 1912312117
Provider Name (Legal Business Name): BORA SHIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 ORANGETHORPE AVE STE 9A
BUENA PARK CA
90621-4668
US

IV. Provider business mailing address

1361 CLEMENTINE WAY
FULLERTON CA
92833-4784
US

V. Phone/Fax

Practice location:
  • Phone: 714-503-6550
  • Fax:
Mailing address:
  • Phone: 817-789-3549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7009
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA147055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: