=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346654290
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY HOON MOON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 91-2141 FORT WEAVER RD
-----------------------------------------------------
City | EWA BEACH
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96706-1993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-691-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 91-2141 FORT WEAVER RD
-----------------------------------------------------
City | EWA BEACH
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96706-1993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-691-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MTL-2017-080
-----------------------------------------------------
License Number State | GU
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A138833
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | M-2073
-----------------------------------------------------
License Number State | GU
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MTL-2017-080
-----------------------------------------------------
License Number State | GU
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | M-2073
-----------------------------------------------------
License Number State | GU
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | M-14568
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD-22072
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------