Active NPI
Ethan Juno Moon
- Student in an Organized Health Care Education/Training Program
- Rockville, MD
National Provider Identifier
1366316259
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Student in an Organized Health Care Education/Training Program
- Practice address
- 11140 Rockville Pike Ste 100
Rockville, MD 20852-3149 - Phone
- (240) 575-6210
- Fax
- (240) 877-0511
- NPI assigned
- Oct 2, 2025
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | Primary |
Addresses
Primary practice location
11140 Rockville Pike Ste 100
Rockville, MD 20852-3149
Mailing address
354 Southwood Dr
Oxford, AL 36203-5020
Phone (240) 575-6210
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1759363200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1759363200000",
"number": "1366316259",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "354 SOUTHWOOD DR",
"city": "OXFORD",
"state": "AL",
"postal_code": "362035020",
"telephone_number": "240-575-6210",
"fax_number": "240-877-0511"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11140 ROCKVILLE PIKE STE 100",
"city": "ROCKVILLE",
"state": "MD",
"postal_code": "208523149",
"telephone_number": "240-575-6210",
"fax_number": "240-877-0511"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOON",
"first_name": "ETHAN",
"middle_name": "JUNO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2025-10-02",
"last_updated": "2025-10-02",
"certification_date": "2025-10-02",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Rockville, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.