Provider Demographics
NPI:1558456319
Name:MOON, JOHN T (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:MOON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:TAE SUNG
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:2111 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3329
Mailing Address - Country:US
Mailing Address - Phone:503-325-4321
Mailing Address - Fax:
Practice Address - Street 1:2055 EXCHANGE ST STE 270
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3419
Practice Address - Country:US
Practice Address - Phone:503-338-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0440321208600000X
ORMD156549208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6603700Medicaid
NY050010Medicare ID - Type Unspecified
NYH45267Medicare UPIN