Kenneth Taeho Moon, M.D.
Individual provider Active NPI Family Medicine Physician · Hollywood, MD
NPI 1972591345 · NPPES record last updated Oct 24, 2025
Key facts
- NPI
- 1972591345
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- D0057219 (MD)
- Practice address
- 24435 Mervell Dean Rd
Hollywood, MD 20636-2712 - Phone
- (301) 373-2116
- NPI assigned
- Oct 11, 2005
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 5
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in DC
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20101222000135 | DC | Practitioner - Family Practice | 2264620947 | Reassigns benefits to 3 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 32929 | DC | MD | Family Medicine Physician |
| D0057219 | MD | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Medstar Medical Group II LLC | Current |
Accepting new patients | |
| MGMC, LLC | Current |
Accepting new patients | |
| Medstar Medical Group II LLC | Current |
Accepting new patients | |
| Signify Health Medical Associates, PLLC | Current |
Accepting new patients | |
| Youngsik Moon, M.D., P.a. | Past |
Accepting new patients |
Locations
1145 19th St NW
Ste 311
Washington, DC 20036
Phone (202) 429-2401
1015 15th St NW
Ste 1000
Washington, DC 20005
Phone (833) 815-2200
3800 Reservoir Rd NW
Washington, DC 20007
Phone (202) 687-2203
18101 Prince Philip Dr
Olney, MD 20832
Phone (301) 774-8618
4055 Valley View Ln
Ste 400
Dallas, TX 75244
Phone (469) 466-7037
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 32929 | DC | |
| Family Medicine Physician | 207Q00000X | D0057219 | MD | Yes |
Addresses
Primary practice location
24435 Mervell Dean Rd
Hollywood, MD 20636-2712
Mailing address
PO Box 37
Hollywood, MD 20636-0037
Phone (301) 373-2116
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 080185963 | Other | DC | MEDICARE RR |
Other providers in Hollywood, MD
- Medstar Medical Group - Southern Maryland LLC
- Medstar Medical Group - Southern Maryland LLC
- Medstar Medical Group II LLC
- Kiran Mehta
- Suzanne Moebius
- Betty Louise Moore
- Mark Mozingo
- Aveek Mukherjee
- National Rehabiliation Hospital, Inc
- National Rehabiliation Hospital, Inc
All providers in Hollywood, MD · Family Medicine Physician in Maryland
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 24, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.