1245447465 NPI number — YOUNGSIK MOON, M.D., P.A.

Table of content: (NPI 1245447465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245447465 NPI number — YOUNGSIK MOON, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUNGSIK MOON, M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245447465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24435 MERVELL DEAN RD
Provider Second Line Business Mailing Address:
PO BOX 37
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20636-2712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-373-2116
Provider Business Mailing Address Fax Number:
301-373-5281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24435 MERVELL DEAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20636-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-373-2116
Provider Business Practice Location Address Fax Number:
301-373-5281
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
QUADE
Authorized Official First Name:
BETTY ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
301-373-2116

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: D09178 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: D09178 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1307 . This is a "CAREFIRST BCBS OF DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1010188 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112048 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2120400 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: KQ75 . This is a "CAREFIRST BCBS OF MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 145464300 . This is a "OWCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: DG3783 . This is a "RAILRAOD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 531541700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5972624 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 818489 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".




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