Basic Information
| Provider Information | |||||||||
| NPI: | 1245407295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | SHINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11614 FM 2244 RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787385471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123995711 | ||||||||
| FaxNumber: | 5123995707 | ||||||||
| Practice Location | |||||||||
| Address1: | 11614 FM 2244 RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787385471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123995711 | ||||||||
| FaxNumber: | 5123995707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016005365 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 1910 | TX | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 1910 | TX | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016005365 | 01 | IL | IL STATE LICENSE | OTHER | 1910 | 01 | TX | STATE OF TEXAS | OTHER |