Basic Information
| Provider Information | |||||||||
| NPI: | 1447220058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | KYOUNG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724 | ||||||||
| Address2: | |||||||||
| City: | MILLBURN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070410724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019430034 | ||||||||
| FaxNumber: | 2019438105 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 LYONS AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071122027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019430034 | ||||||||
| FaxNumber: | 2019438105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MA03401700 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 4837703 | 05 | NJ | MEDICAID | D92539 | 01 | NJ | UNIVERSAL PROVIDER NUMBER | OTHER |