Provider Demographics
NPI:1437107034
Name:MOON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3266
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3266
Mailing Address - Country:US
Mailing Address - Phone:904-819-4602
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:7707 PARAGON RD STE 101
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-208-6920
Practice Address - Fax:937-208-6948
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79597207R00000X
OH35.126007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49676WMedicare PIN
FL274215200Medicaid