Provider Demographics
NPI:1902843972
Name:MOON, TAEWON
Entity Type:Individual
Prefix:DR
First Name:TAEWON
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 HUDSON TER
Mailing Address - Street 2:SUITE#102
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2902
Mailing Address - Country:US
Mailing Address - Phone:201-503-0066
Mailing Address - Fax:201-503-0190
Practice Address - Street 1:464 HUDSON TER
Practice Address - Street 2:SUITE#102
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2902
Practice Address - Country:US
Practice Address - Phone:201-503-0066
Practice Address - Fax:201-503-0190
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05670900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ688587Medicare ID - Type Unspecified