Provider Demographics
NPI:1366316259
Name:MOON, ETHAN JUNO
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JUNO
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36203-5020
Mailing Address - Country:US
Mailing Address - Phone:240-575-6210
Mailing Address - Fax:240-877-0511
Practice Address - Street 1:11140 ROCKVILLE PIKE STE 100
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3149
Practice Address - Country:US
Practice Address - Phone:240-575-6210
Practice Address - Fax:240-877-0511
Is Sole Proprietor?:No
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program