Provider Demographics
NPI:1598753956
Name:MOON, JONG YEOUNG (MD)
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:YEOUNG
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24511 WEST JAYNE AVE P.O BOX 5002
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-5002
Mailing Address - Country:US
Mailing Address - Phone:559-935-4300
Mailing Address - Fax:
Practice Address - Street 1:24511 W JAYNE AVE
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-9503
Practice Address - Country:US
Practice Address - Phone:559-935-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52501207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH35061Medicare UPIN
NJ047193Medicare ID - Type Unspecified
NJ8856206Medicaid