Basic Information
| Provider Information | |||||||||
| NPI: | 1689690398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | OH SUNG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1810 E 19TH ST STE 225 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412966101 | ||||||||
| FaxNumber: | 5412960025 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 E 19TH ST STE 225 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412966101 | ||||||||
| FaxNumber: | 5412960025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD18425 | OR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 056940 | 05 | OR | MEDICAID | 8149056 | 05 | WA | MEDICAID |