Provider Demographics
NPI:1972603637
Name:MOON, TAEWHA CAROLYN (OD)
Entity Type:Individual
Prefix:DR
First Name:TAEWHA
Middle Name:CAROLYN
Last Name:MOON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BROAD AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1590
Mailing Address - Country:US
Mailing Address - Phone:201-585-1337
Mailing Address - Fax:201-585-2998
Practice Address - Street 1:225 BROAD AVE STE 206
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1590
Practice Address - Country:US
Practice Address - Phone:201-585-1337
Practice Address - Fax:201-585-2998
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00465400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5084601Medicaid
084328Medicare ID - Type Unspecified
NJ5084601Medicaid