MEDICARE: DR. SHINTO JACOB KOSHY M.D.

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	208VP0014X	Interventional Pain Medicine Physician	A139304	CA
2	208100000X	Physical Medicine & Rehabilitation Physician	A139304	CA

General Provider Information

NPI Number	:	1780816314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHINTO JACOB KOSHY M.D.

Provider Business Mailing Address
First Line	:	1041 E YORBA LINDA BLVD STE 210
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-3763
Country	:	US
Telephone Number	:	818-386-6358
Fax Number	:	714-223-7000

Provider Business Practice Location Address
First Line	:	1041 E YORBA LINDA BLVD STE 210
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-3763
Country	:	US
Telephone Number	:	818-386-6358
Fax Number	:	714-223-7000

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

Provider Enumeration Date	:	08/15/2009
Last Update Date	:	10/20/2021

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