Provider Demographics
NPI:1669069696
Name:KIM, SUN MOON (DO)
Entity type:Individual
Prefix:DR
First Name:SUN MOON
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 CITY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-6690
Mailing Address - Fax:215-871-6695
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6690
Practice Address - Fax:215-871-6695
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2025-04-29
Deactivation Date:2025-03-28
Deactivation Code:
Reactivation Date:2025-04-16
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03972600183500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183500000XPharmacy Service ProvidersPharmacist