Provider Demographics
NPI:1912312117
Name:SHIN, BORA (MD)
Entity type:Individual
Prefix:
First Name:BORA
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 CLEMENTINE WAY
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4784
Mailing Address - Country:US
Mailing Address - Phone:817-789-3549
Mailing Address - Fax:
Practice Address - Street 1:7212 ORANGETHORPE AVE STE 9A
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4668
Practice Address - Country:US
Practice Address - Phone:714-503-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7009208000000X
CAA147055208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics