Provider Demographics
NPI:1639506991
Name:KIM, SUN JOO
Entity Type:Individual
Prefix:MRS
First Name:SUN JOO
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21519 39TH AVE
Mailing Address - Street 2:505
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2114
Mailing Address - Country:US
Mailing Address - Phone:718-229-0707
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRE ST
Practice Address - Street 2:505
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4552
Practice Address - Country:US
Practice Address - Phone:212-274-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist