Provider Demographics
NPI:1083078315
Name:MOON, JUNG JOO (MD, MMS)
Entity type:Individual
Prefix:
First Name:JUNG
Middle Name:JOO
Last Name:MOON
Suffix:
Gender:
Credentials:MD, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 LAKEWOOD AVE SW STE 1138
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-5801
Mailing Address - Country:US
Mailing Address - Phone:713-904-0106
Mailing Address - Fax:862-227-4081
Practice Address - Street 1:2875 LAKEWOOD AVE SW # A5
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-5801
Practice Address - Country:US
Practice Address - Phone:713-904-0106
Practice Address - Fax:862-227-4081
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN70750207ZP0102X
WI76451208D00000X
TX646517390200000X
GA90144208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program