Provider Demographics
NPI:1043455306
Name:MOON, DAVIS SUNGWHAN (MD)
Entity type:Individual
Prefix:
First Name:DAVIS
Middle Name:SUNGWHAN
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 1:4750 WATERS AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6261
Mailing Address - Country:US
Mailing Address - Phone:912-352-8346
Mailing Address - Fax:
Practice Address - Street 1:4750 WATERS AVE STE 500
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6261
Practice Address - Country:US
Practice Address - Phone:912-352-8346
Practice Address - Fax:912-355-5515
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC849132086S0129X
GA742072086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003223457HMedicaid
GA003223457AMedicaid