Provider Demographics
NPI:1780646083
Name:MOON, HENRY S (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:S
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2098 TERON TRACE
Mailing Address - Street 2:STE150
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1662
Mailing Address - Country:US
Mailing Address - Phone:678-730-1620
Mailing Address - Fax:678-730-0858
Practice Address - Street 1:2098 TERON TRCE
Practice Address - Street 2:STE150
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1662
Practice Address - Country:US
Practice Address - Phone:678-730-1620
Practice Address - Fax:678-730-0858
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA038311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBVLHMedicare ID - Type Unspecified
G42713Medicare UPIN