Provider Demographics
NPI:1528700846
Name:SHIN, BENJAMIN (DO)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 DULUTH HWY STE 501
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8709
Mailing Address - Country:US
Mailing Address - Phone:678-312-0400
Mailing Address - Fax:678-312-0423
Practice Address - Street 1:665 DULUTH HWY STE 501
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8709
Practice Address - Country:US
Practice Address - Phone:678-312-0400
Practice Address - Fax:678-312-0423
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103705207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine