Provider Demographics
NPI:1477581270
Name:MOON, THERESA KYUNGHOI-KIM (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:KYUNGHOI-KIM
Last Name:MOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18692 PATRICIAN DR
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92861-4211
Mailing Address - Country:US
Mailing Address - Phone:714-633-0184
Mailing Address - Fax:714-543-4488
Practice Address - Street 1:2813 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5942
Practice Address - Country:US
Practice Address - Phone:951-737-2962
Practice Address - Fax:951-737-2783
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA434822084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E30284Medicare ID - Type Unspecified