Provider Demographics
NPI:1447220058
Name:MOON, KYOUNG (MD)
Entity Type:Individual
Prefix:
First Name:KYOUNG
Middle Name:
Last Name:MOON
Suffix:
Gender:F
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:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-0724
Mailing Address - Country:US
Mailing Address - Phone:201-943-0034
Mailing Address - Fax:201-943-8105
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:201-943-0034
Practice Address - Fax:201-943-8105
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03401700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4837703Medicaid
NJD92539OtherUNIVERSAL PROVIDER NUMBER
NJ461490Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER