Provider Demographics
NPI:1114088507
Name:MOON, HARRY K (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:K
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 1:717 SE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3605
Mailing Address - Country:US
Mailing Address - Phone:954-357-1172
Mailing Address - Fax:954-337-3309
Practice Address - Street 1:717 SE 2ND ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3605
Practice Address - Country:US
Practice Address - Phone:954-493-5005
Practice Address - Fax:954-337-3309
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51849174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04903OtherBLUECROSSBLUESHIELD OF FL
FL04903XMedicare ID - Type Unspecified
FL04903OtherBLUECROSSBLUESHIELD OF FL