Healthcare Provider Details

I. General information

NPI: 1194139253
Provider Name (Legal Business Name): DAVID SHIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OCONNOR DR SUITE 250
SAN JOSE CA
95128-1633
US

IV. Provider business mailing address

450 E SPRING ST STE 1
LONG BEACH CA
90806-1625
US

V. Phone/Fax

Practice location:
  • Phone: 408-283-7676
  • Fax:
Mailing address:
  • Phone: 562-933-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA138961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: