Provider Demographics
NPI:1558456319
Name:MOON, JOHN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:TAE SUNG
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:9301 W 74TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2207
Mailing Address - Country:US
Mailing Address - Phone:913-632-9200
Mailing Address - Fax:913-632-9209
Practice Address - Street 1:9301 W 74TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2207
Practice Address - Country:US
Practice Address - Phone:913-632-9200
Practice Address - Fax:913-632-9209
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0440321208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6603700Medicaid
NY050010Medicare ID - Type Unspecified
NYH45267Medicare UPIN