Provider Demographics
NPI:1669441689
Name:MOON, JUNG (DPM)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 E CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1518
Mailing Address - Country:US
Mailing Address - Phone:847-573-1157
Mailing Address - Fax:224-513-5458
Practice Address - Street 1:270 E CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1518
Practice Address - Country:US
Practice Address - Phone:847-573-1157
Practice Address - Fax:224-513-5458
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004899213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932398OtherBCBSIL
IL5338400001Medicare NSC
ILV04047Medicare UPIN
ILK15071Medicare ID - Type Unspecified