Basic Information
| Provider Information | |||||||||
| NPI: | 1740654078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | SEUNGCHUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14350 MERIDIAN PKWY | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925183035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518271012 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514864000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2015 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 125.071701 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 174390 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.