Provider Demographics
NPI:1093738932
Name:KIM, SUN IK (MD)
Entity Type:Individual
Prefix:
First Name:SUN
Middle Name:IK
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4816
Mailing Address - Country:US
Mailing Address - Phone:909-882-2973
Mailing Address - Fax:909-882-2681
Practice Address - Street 1:489 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4816
Practice Address - Country:US
Practice Address - Phone:909-882-2973
Practice Address - Fax:909-882-2681
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69380208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A693801Medicaid
CA00A693801OtherBLUE CROSS & BLUE SHIELD
CA00A693801Medicare ID - Type Unspecified
CAH70964Medicare UPIN