Healthcare Provider Details

I. General information

NPI: 1275222127
Provider Name (Legal Business Name): SUNGJIN IM PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 SURF ST
LINDENHURST NY
11757-6238
US

IV. Provider business mailing address

100 DUFFY AVE STE 510
HICKSVILLE NY
11801-3636
US

V. Phone/Fax

Practice location:
  • Phone: 270-681-0773
  • Fax:
Mailing address:
  • Phone: 270-681-0773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number024766
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number276794
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: