MEDICARE: JUNG JOO MOON M.D., M.M.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	70750	MN
2	208D00000X	General Practice Physician	76451	WI
3	390200000X	Student in an Organized Health Care Education/Training Program	646517	TX
4	208D00000X	General Practice Physician	90144	GA

General Provider Information

NPI Number	:	1083078315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUNG JOO MOON M.D., M.M.S

Provider Business Mailing Address
First Line	:	2875 LAKEWOOD AVE SW STE 1138
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-5801
Country	:	US
Telephone Number	:	713-904-0106
Fax Number	:	862-227-4081

Provider Business Practice Location Address
First Line	:	2875 LAKEWOOD AVE SW # A5
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-5801
Country	:	US
Telephone Number	:	713-904-0106
Fax Number	:	862-227-4081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	04/23/2025

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