Healthcare Provider Details

I. General information

NPI: 1477581270
Provider Name (Legal Business Name): THERESA KYUNGHOI-KIM MOON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2813 S MAIN ST
CORONA CA
92882-5942
US

IV. Provider business mailing address

18692 PATRICIAN DR
VILLA PARK CA
92861-4211
US

V. Phone/Fax

Practice location:
  • Phone: 951-737-2962
  • Fax: 951-737-2783
Mailing address:
  • Phone: 714-633-0184
  • Fax: 714-543-4488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberA43482
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: