Provider Demographics
NPI:1982821799
Name:MOON, THOMAS J JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:MOON
Suffix:JR
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 40767
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:
Practice Address - Street 1:841 PRUDENTIAL DR STE 280
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8350
Practice Address - Country:US
Practice Address - Phone:904-202-8550
Practice Address - Fax:904-393-7808
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR470062080P0202X
390200000X
FLME1131072080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125542AMedicaid
FL14KY8OtherBCBS
FL005915000Medicaid
FLGH309ZMedicare PIN