Provider Demographics
NPI:1346654290
Name:MOON, TIMOTHY HOON (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:HOON
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 1:91-2141 FORT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1993
Mailing Address - Country:US
Mailing Address - Phone:808-691-3000
Mailing Address - Fax:
Practice Address - Street 1:91-2141 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1993
Practice Address - Country:US
Practice Address - Phone:808-691-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUMTL-2017-080207Q00000X, 207R00000X
CAA138833207Q00000X
GUM-2073207Q00000X, 207R00000X
IDM-14568208M00000X
HIMD-22072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI002163Medicaid