=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992791495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKE S. SHIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2005
-----------------------------------------------------
Last Update Date | 09/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 W. SEVENTH ST.
-----------------------------------------------------
City | HANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93230-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-585-7252
-----------------------------------------------------
Fax | 559-585-7253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 860 W. SEVENTH ST.
-----------------------------------------------------
City | HANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93230-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-585-7252
-----------------------------------------------------
Fax | 559-585-7253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 22219
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207YP0228X
-----------------------------------------------------
Taxonomy Name | Pediatric Otolaryngology Physician
-----------------------------------------------------
License Number | 22219
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207YS0123X
-----------------------------------------------------
Taxonomy Name | Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 22219
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207YX0602X
-----------------------------------------------------
Taxonomy Name | Otolaryngic Allergy Physician
-----------------------------------------------------
License Number | 22219
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | A97516
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------