Provider Demographics
NPI:1639146558
Name:KIM, SUNNY R (MD)
Entity Type:Individual
Prefix:
First Name:SUNNY
Middle Name:R
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 1:6005 ROCKWELL DR NE STE B
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-7228
Mailing Address - Country:US
Mailing Address - Phone:319-393-1320
Mailing Address - Fax:319-393-1350
Practice Address - Street 1:6005 ROCKWELL DR NE STE B
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-393-1320
Practice Address - Fax:319-393-1350
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35982208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1468462Medicaid
I143803Medicare UPIN
IAI16227Medicare ID - Type Unspecified