Provider Demographics
NPI:1437410354
Name:MOON, JEONGHUN (MD)
Entity Type:Individual
Prefix:
First Name:JEONGHUN
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:4033 TALBOT RD S STE 440
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5767
Practice Address - Country:US
Practice Address - Phone:425-690-3494
Practice Address - Fax:425-690-9494
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60538616207RR0500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046049Medicaid