Provider Demographics
NPI:1215294756
Name:SHIN, MATTHEW JAESIK (DC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAESIK
Last Name:SHIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13860 BRADDOCK RD STE E
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2401
Mailing Address - Country:US
Mailing Address - Phone:703-815-7246
Mailing Address - Fax:866-205-8716
Practice Address - Street 1:13860 BRADDOCK RD STE E
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2401
Practice Address - Country:US
Practice Address - Phone:703-815-7246
Practice Address - Fax:866-205-8716
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556896111N00000X
MD03681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor