Provider Demographics
NPI:1033158282
Name:SUN, JIDONG
Entity Type:Individual
Prefix:
First Name:JIDONG
Middle Name:
Last Name:SUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 KUSER RD STE B3
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3829
Mailing Address - Country:US
Mailing Address - Phone:732-888-3300
Mailing Address - Fax:732-888-3116
Practice Address - Street 1:1542 KUSER RD STE B3
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3829
Practice Address - Country:US
Practice Address - Phone:732-888-3300
Practice Address - Fax:732-888-3116
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA70679208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0073539Medicaid
NJ0073539Medicaid
NJH25170Medicare UPIN