Healthcare Provider Details

I. General information

NPI: 1972591345
Provider Name (Legal Business Name): KENNETH TAEHO MOON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24435 MERVELL DEAN RD
HOLLYWOOD MD
20636-2712
US

IV. Provider business mailing address

PO BOX 37
HOLLYWOOD MD
20636-0037
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32929
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0057219
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: