Provider Demographics
NPI:1013632934
Name:MOON, KYUNGMI (SONOGRAPHER)
Entity Type:Individual
Prefix:
First Name:KYUNGMI
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:SONOGRAPHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4929 BROOKBURN DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2779
Mailing Address - Country:US
Mailing Address - Phone:858-775-2428
Mailing Address - Fax:
Practice Address - Street 1:767 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2031
Practice Address - Country:US
Practice Address - Phone:858-703-7067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2503032471V0105X, 2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography