Provider Demographics
NPI:1962527846
Name:SHIN, JISOO L (OD)
Entity type:Individual
Prefix:DR
First Name:JISOO
Middle Name:L
Last Name:SHIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 HEATH PL
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-3619
Mailing Address - Country:US
Mailing Address - Phone:914-479-1578
Mailing Address - Fax:
Practice Address - Street 1:971 CENTRAL PARK AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-3211
Practice Address - Country:US
Practice Address - Phone:914-723-7392
Practice Address - Fax:914-723-1004
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00549600152W00000X
NJ27TO00087000152W00000X
NYT006053-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU97470Medicare UPIN
NJ074157R6DMedicare ID - Type Unspecified