Healthcare Provider Details

I. General information

NPI: 1114954583
Provider Name (Legal Business Name): SYDNEY SUMI MOON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUMI MOON M.D.

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST LIFESPAN PHYSCIAN GROUP
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST LIFESPAN PHYSCIAN GROUP
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-2128
  • Fax: 401-444-8836
Mailing address:
  • Phone: 401-444-2128
  • Fax: 401-444-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number14228
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: