Healthcare Provider Details

I. General information

NPI: 1649226440
Provider Name (Legal Business Name): SANG O SHIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5180
US

IV. Provider business mailing address

905 MADISON ST NE
ALBUQUERQUE NM
87110-6214
US

V. Phone/Fax

Practice location:
  • Phone: 265-171-1505
  • Fax:
Mailing address:
  • Phone: 505-239-9435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-9682
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number11099
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number10564
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2013-0642
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: