Basic Information
| Provider Information | |||||||||
| NPI: | 1316999055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | CHUL SO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550928013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519827000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5200 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550928013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519827000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | LT4202 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 27463 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 20654 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 290840 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | D54806 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | MD442671 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 69841 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 699108400 | 05 | MD | MEDICAID |