Basic Information
| Provider Information | |||||||||
| NPI: | 1982628756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 946 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923540946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512730136 | ||||||||
| FaxNumber: | 9518489121 | ||||||||
| Practice Location | |||||||||
| Address1: | 12000 MOUNT VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923135174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512730136 | ||||||||
| FaxNumber: | 9518489121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A42601 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A426010 | 05 | CA | MEDICAID |