Provider Demographics
NPI:1316122104
Name:IM, SUNG (MD)
Entity type:Individual
Prefix:
First Name:SUNG
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 E TEMPLE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-2329
Mailing Address - Country:US
Mailing Address - Phone:703-344-4855
Mailing Address - Fax:
Practice Address - Street 1:1225 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1901
Practice Address - Country:US
Practice Address - Phone:213-977-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117206207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFH954ZMedicare PIN