Provider Demographics
NPI:1104851237
Name:SHIN, BRYANT J (MD)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:J
Last Name:SHIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 LEGACY OAK TRAIL
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534
Mailing Address - Country:US
Mailing Address - Phone:585-249-0087
Mailing Address - Fax:
Practice Address - Street 1:973 EAST AVENUE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607
Practice Address - Country:US
Practice Address - Phone:585-442-1515
Practice Address - Fax:585-442-8376
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225028207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H69516Medicare UPIN
10990AMedicare ID - Type Unspecified