Provider Demographics
NPI:1568417509
Name:MOON, MIA KWUN (MD/)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:KWUN
Last Name:MOON
Suffix:
Gender:F
Credentials:MD/
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:O
Other - Last Name:KWUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3736 CLARKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2634
Mailing Address - Country:US
Mailing Address - Phone:951-538-8081
Mailing Address - Fax:
Practice Address - Street 1:2500 WEST FWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5848
Practice Address - Country:US
Practice Address - Phone:817-882-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62310207Q00000X
TXP5690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A623100Medicaid
CA00A623100Medicaid