Basic Information
| Provider Information | |||||||||
| NPI: | 1477581270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | KYUNGHOI-KIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18692 PATRICIAN DR | ||||||||
| Address2: | |||||||||
| City: | VILLA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928614211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146330184 | ||||||||
| FaxNumber: | 7145434488 | ||||||||
| Practice Location | |||||||||
| Address1: | 2813 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928825942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372962 | ||||||||
| FaxNumber: | 9517372783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084F0202X | A43482 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry |
No ID Information.