MEDICARE: DR. JAE YOON SHIN D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	N00721001	NY
2	213E00000X	Podiatrist	POD001311	GA
3	213EP1101X	Primary Podiatric Medicine Podiatrist	25MD00365800	NJ
4	213ES0103X	Foot & Ankle Surgery Podiatrist	25MD00365800	NJ
5	213E00000X	Podiatrist	25MD00365800	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	25MD00365800	OTHER	NJ	PODIATRIC LICENSE
2	POD001311	OTHER	GA	PODIATRIC LICENSE
3	N007210-01	OTHER	NY	PODIATRIC LICENSE

General Provider Information

NPI Number	:	1396088803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAE YOON SHIN D.P.M.

Provider Business Mailing Address
First Line	:	4220 27TH ST APT 515
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-8618
Country	:	US
Telephone Number	:	267-269-7127
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 27TH ST APT 515
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-8618
Country	:	US
Telephone Number	:	267-269-7127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2013
Last Update Date	:	02/01/2022

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Directions to “ DR. JAE YOON SHIN D.P.M.” Practice Location

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