Provider Demographics
NPI:1831203215
Name:YOUNGSIK MOON, M.D., P.A.
Entity type:Organization
Organization Name:YOUNGSIK MOON, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-373-2116
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:301-373-5281
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:301-373-5281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1200261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134736OtherAETNA HMO
5108771OtherAETNA
199904-02OtherAMERIGROUP
250800OtherMAMSI
0008273OtherCIGNA
MD57494301OtherCAREFIRST
DCPL8OtherCAREFIRST
MD029JOtherCAREFIRST
5607239OtherFIRST HEALTH/CCN
199904-02OtherAMERIGROUP
5108771OtherAETNA
P00171000Medicare ID - Type UnspecifiedRAILROAD MEDICARE