Provider Demographics
NPI:1689690398
Name:MOON, PAUL OH SUNG (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:OH SUNG
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 1:1810 E 19TH ST STE 225
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3388
Mailing Address - Country:US
Mailing Address - Phone:541-296-6101
Mailing Address - Fax:541-296-0025
Practice Address - Street 1:1810 E 19TH ST STE 225
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-6101
Practice Address - Fax:541-296-0025
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18425208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR056940Medicaid
WA8149056Medicaid
WA8853808Medicare PIN
ORR183268Medicare UPIN
OR330002704Medicare PIN
F59053Medicare UPIN
OR00WCJJFCMedicare PIN