Provider Demographics
NPI:1568438455
Name:MOON, THEODORE HYUNSUB (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:HYUNSUB
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-251-2600
Mailing Address - Fax:435-251-2610
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:SUITE 2200
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-251-2600
Practice Address - Fax:435-251-2610
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60692207RC0200X, 207RP1001X
UT8288624-8017207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A606920Medicaid
CAH52941Medicare UPIN
CAW481Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER