Provider Demographics
NPI:1043770241
Name:MOON, PEROUNSACK X (DO)
Entity Type:Individual
Prefix:DR
First Name:PEROUNSACK
Middle Name:X
Last Name:MOON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:ZACK
Other - Middle Name:X
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:380 HOSPITAL DR STE 430
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-8017
Mailing Address - Country:US
Mailing Address - Phone:478-751-0367
Mailing Address - Fax:
Practice Address - Street 1:380 HOSPITAL DR STE 430
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8017
Practice Address - Country:US
Practice Address - Phone:478-751-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program