Provider Demographics
NPI:1518074046
Name:KIM, MOON JA (MD)
Entity Type:Individual
Prefix:DR
First Name:MOON JA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:W231 N1440 CORPORATE CT
Practice Address - Street 2:#310
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186
Practice Address - Country:US
Practice Address - Phone:262-896-6186
Practice Address - Fax:262-896-6139
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI354492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32463200Medicaid
WI32463200Medicaid
G77508Medicare UPIN
WI32463200Medicaid