Provider Demographics
NPI:1043704547
Name:IM, MOONHWAN
Entity Type:Individual
Prefix:
First Name:MOONHWAN
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MOON
Other - Middle Name:
Other - Last Name:IM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8195 PRESIDIO DR
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-4027
Mailing Address - Country:US
Mailing Address - Phone:707-696-0800
Mailing Address - Fax:
Practice Address - Street 1:730 E EL CAMINO REAL STE B
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2971
Practice Address - Country:US
Practice Address - Phone:408-426-8281
Practice Address - Fax:833-305-0201
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18114171100000X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4252817OtherSTATE FILE NUMBER