Provider Demographics
NPI:1174516934
Name:MOON, MARTIN RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:RYAN
Last Name:MOON
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-578-5800
Mailing Address - Fax:589-578-5881
Practice Address - Street 1:4900 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4824
Practice Address - Country:US
Practice Address - Phone:859-578-5880
Practice Address - Fax:859-578-5881
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-070819208600000X
KY39444208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64108491Medicaid
KY64108491Medicaid
KYK008100Medicare PIN
KY0713905Medicare PIN