Healthcare Provider Details

I. General information

NPI: 1568438455
Provider Name (Legal Business Name): THEODORE HYUNSUB MOON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 E MEDICAL CENTER DR SUITE 2200
ST GEORGE UT
84790-2123
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-251-2600
  • Fax: 435-251-2610
Mailing address:
  • Phone: 435-251-2600
  • Fax: 435-251-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA60692
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA60692
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number8288624-8017
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number8288624-8017
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: