Basic Information
Provider Information | |||||||||
NPI: | 1760595755 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOON | ||||||||
FirstName: | TAESUN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 161 KENWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | ONEIDA | ||||||||
State: | NY | ||||||||
PostalCode: | 134212829 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7184964981 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 600 SOMERSET AVE | ||||||||
Address2: |   | ||||||||
City: | WINDBER | ||||||||
State: | PA | ||||||||
PostalCode: | 159631331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144674750 | ||||||||
FaxNumber: | 8144674751 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2006 | ||||||||
LastUpdateDate: | 10/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 240499 | NY | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | OS016770 | 01 | PA | MEDICAL LICENSE | OTHER | 2808280 | 05 | NY |   | MEDICAID |