Provider Demographics
NPI:1831259878
Name:MOON, KYOUNG JA (MD)
Entity type:Individual
Prefix:
First Name:KYOUNG
Middle Name:JA
Last Name:MOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6356
Mailing Address - Country:US
Mailing Address - Phone:718-494-5312
Mailing Address - Fax:718-494-2258
Practice Address - Street 1:1050 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6356
Practice Address - Country:US
Practice Address - Phone:718-494-5312
Practice Address - Fax:718-494-2258
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125640-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00247310Medicaid
NYD39042Medicare UPIN
NY85I061Medicare PIN