Healthcare Provider Details

I. General information

NPI: 1326093980
Provider Name (Legal Business Name): WONG KYUN MOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 13TH AVE S STE 101
GREAT FALLS MT
59405-4300
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-2831
  • Fax: 406-455-2824
Mailing address:
  • Phone: 510-204-8168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number171635
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number266214
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number266214
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: