Basic Information
| Provider Information | |||||||||
| NPI: | 1437107034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3266 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048194602 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 7707 PARAGON RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372086920 | ||||||||
| FaxNumber: | 9372086948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME79597 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.126007 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.