Provider Demographics
NPI:1780779819
Name:DONG S. MOON,M.D.INC.,
Entity type:Organization
Organization Name:DONG S. MOON,M.D.INC.,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONG
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-434-6131
Mailing Address - Street 1:6728 LOOP RD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2196
Mailing Address - Country:US
Mailing Address - Phone:937-434-6131
Mailing Address - Fax:937-434-8909
Practice Address - Street 1:6728 LOOP RD.
Practice Address - Street 2:SUITE 201
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2196
Practice Address - Country:US
Practice Address - Phone:937-434-6131
Practice Address - Fax:937-434-8909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 1041C0700X
OH350418212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========00OtherWORKERS COMP