Provider Demographics
NPI:1386791143
Name:SHIN, CHUNG K (MD)
Entity type:Individual
Prefix:DR
First Name:CHUNG
Middle Name:K
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 1:91 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5020
Mailing Address - Country:US
Mailing Address - Phone:203-855-9806
Mailing Address - Fax:203-855-1135
Practice Address - Street 1:91 EAST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5020
Practice Address - Country:US
Practice Address - Phone:203-855-9806
Practice Address - Fax:203-855-1135
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037720174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0V7050OtherHEALTHNET
CT01377200CT03OtherBLUE CROSS
CTP2061278OtherOXFORD
CT037720OtherCONNECTICARE
CT178311OtherWELLCARE
CT2322912OtherAETNA
CT3324246-004OtherCIGNA
CT037720OtherCONNECTICARE