Provider Demographics
NPI:1972591345
Name:MOON, KENNETH TAEDO (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:TAEDO
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0037
Mailing Address - Country:US
Mailing Address - Phone:301-373-2116
Mailing Address - Fax:
Practice Address - Street 1:24435 MERVELL DEAN RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-2712
Practice Address - Country:US
Practice Address - Phone:301-373-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC32929207Q00000X
MDD0057219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC080185963OtherMEDICARE RR
DC009302G65Medicare PIN
DC080185963OtherMEDICARE RR
H43389Medicare UPIN