Provider Demographics
NPI:1316194574
Name:MOON, JONAH RALPH (MD)
Entity type:Individual
Prefix:DR
First Name:JONAH
Middle Name:RALPH
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 E MAIN ST
Mailing Address - Street 2:BOX 328
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-5818
Mailing Address - Country:US
Mailing Address - Phone:330-593-1049
Mailing Address - Fax:330-572-3836
Practice Address - Street 1:1675 E MAIN ST
Practice Address - Street 2:BOX 328
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-5818
Practice Address - Country:US
Practice Address - Phone:330-593-1049
Practice Address - Fax:330-572-3836
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1240952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109133Medicaid
P01383997OtherRR MEDICARE
OHH374270Medicare PIN