Provider Demographics
NPI:1114954583
Name:MOON, SYDNEY SUMI (MD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:SUMI
Last Name:MOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUMI
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:LIFESPAN PHYSCIAN GROUP
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-2128
Mailing Address - Fax:401-444-8836
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:LIFESPAN PHYSCIAN GROUP
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-2128
Practice Address - Fax:401-444-8836
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI142282084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110073955AMedicaid
MAA40186Medicare PIN