Healthcare Provider Details

I. General information

NPI: 1992966717
Provider Name (Legal Business Name): JONG T SHIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 HADDONFIELD RD # 3B
CHERRY HILL NJ
08002-2783
US

IV. Provider business mailing address

951 HADDONFIELD RD BLDG A13
CHERRY HILL NJ
08002-2783
US

V. Phone/Fax

Practice location:
  • Phone: 856-270-6800
  • Fax: 856-324-5958
Mailing address:
  • Phone: 856-270-6800
  • Fax: 856-324-5958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS013428
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS013428
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB08427400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: