Provider Demographics
NPI:1831106301
Name:MOON, KYUNG-WOONG (MD)
Entity Type:Individual
Prefix:DR
First Name:KYUNG-WOONG
Middle Name:
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 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2007
Mailing Address - Fax:810-743-1099
Practice Address - Street 1:1096 S BELSAY RD
Practice Address - Street 2:SUITE J
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-715-0803
Practice Address - Fax:810-715-0824
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010348782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3008204811OtherBCBSM INDIVIDUAL PIN
MI4765404Medicaid
MIM23560159Medicare PIN
MI3008204811OtherBCBSM INDIVIDUAL PIN