Provider Demographics
NPI:1396088803
Name:SHIN, JAE YOON (DPM)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:YOON
Last Name:SHIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 27TH ST APT 515
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-8618
Mailing Address - Country:US
Mailing Address - Phone:267-269-7127
Mailing Address - Fax:
Practice Address - Street 1:4220 27TH ST APT 515
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-8618
Practice Address - Country:US
Practice Address - Phone:267-269-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN00721001213E00000X
GAPOD001311213E00000X
NJ25MD00365800213EP1101X, 213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MD00365800OtherPODIATRIC LICENSE
GAPOD001311OtherPODIATRIC LICENSE
NYN007210-01OtherPODIATRIC LICENSE