Provider Demographics
NPI:1760545925
Name:MOON, JONG CHUN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONG
Middle Name:CHUN
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 1:406 JAMES ST.
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263
Mailing Address - Country:US
Mailing Address - Phone:661-746-5788
Mailing Address - Fax:661-746-5273
Practice Address - Street 1:406 JAMES ST
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-2035
Practice Address - Country:US
Practice Address - Phone:661-746-5788
Practice Address - Fax:661-746-5273
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A356070208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53818FMedicaid
CARHM53818FMedicaid
CA553818AMedicare ID - Type Unspecified