Provider Demographics
NPI:1982696605
Name:KIM, MOON Y (MD)
Entity Type:Individual
Prefix:DR
First Name:MOON
Middle Name:Y
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 1:36 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-2004
Mailing Address - Country:US
Mailing Address - Phone:201-825-3454
Mailing Address - Fax:
Practice Address - Street 1:36 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:UPPER SADDLE RIVER
Practice Address - State:NJ
Practice Address - Zip Code:07458-2004
Practice Address - Country:US
Practice Address - Phone:201-825-3454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02776100207L00000X
NY118587207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00347860Medicaid
NJ1092006Medicaid
NY00347860Medicaid
NY8L160YRXP1Medicare PIN
NY8L160ZT5H1Medicare PIN
NY8L1601Medicare PIN
NYB18822Medicare UPIN
NY8L160ZXWW1Medicare PIN
NJ450011Medicare PIN