Provider Demographics
NPI:1457578403
Name:JONG C MOON MD INC
Entity Type:Organization
Organization Name:JONG C MOON MD INC
Other - Org Name:SHAFTER RURAL HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONG
Authorized Official - Middle Name:CHUN
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-746-5788
Mailing Address - Street 1:406 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-2035
Mailing Address - Country:US
Mailing Address - Phone:661-746-5788
Mailing Address - Fax:661-746-5273
Practice Address - Street 1:406 JAMES ST
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-2035
Practice Address - Country:US
Practice Address - Phone:661-746-5788
Practice Address - Fax:661-746-5273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA356070261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53818FMedicaid
CA553818AMedicare PIN
CAOOA356070Medicare UPIN
CA553818AMedicare Oscar/Certification