Healthcare Provider Details

I. General information

NPI: 1245447465
Provider Name (Legal Business Name): YOUNGSIK MOON, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24435 MERVELL DEAN RD
HOLLYWOOD MD
20636-2712
US

IV. Provider business mailing address

24435 MERVELL DEAN RD PO BOX 37
HOLLYWOOD MD
20636-2712
US

V. Phone/Fax

Practice location:
  • Phone: 301-373-2116
  • Fax: 301-373-5281
Mailing address:
  • Phone: 301-373-2116
  • Fax: 301-373-5281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD09178
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD09178
License Number StateMD

VIII. Authorized Official

Name: MS. BETTY ANN QUADE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 301-373-2116