Provider Demographics
NPI:1083293112
Name:PARK, MOON JOON (MD)
Entity type:Individual
Prefix:
First Name:MOON
Middle Name:JOON
Last Name:PARK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 E HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1313 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3306
Practice Address - Country:US
Practice Address - Phone:559-450-5372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAA192818208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program