Provider Demographics
NPI:1104921063
Name:YIM, SUN(SUSAN) W (DO)
Entity type:Individual
Prefix:
First Name:SUN(SUSAN)
Middle Name:W
Last Name:YIM
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 HYLAND CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3591
Mailing Address - Country:US
Mailing Address - Phone:217-840-5841
Mailing Address - Fax:
Practice Address - Street 1:1149 SEMINOLE TRL
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2897
Practice Address - Country:US
Practice Address - Phone:434-978-3998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203731207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001OtherDMERC
ILK10076Medicare PIN
H24268Medicare UPIN
ILIL3270032Medicare PIN
IL6447860004Medicare NSC
IL0533210001OtherDMERC