Healthcare Provider Details

I. General information

NPI: 1912400730
Provider Name (Legal Business Name): JOHN MOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24600 W 127TH ST
PLAINFIELD IL
60585-9507
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-7000
  • Fax:
Mailing address:
  • Phone: 847-570-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036169368
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: