1235199845 NPI number — DENNIS MOON MD

Table of content: DENNIS MOON MD (NPI 1235199845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235199845 NPI number — DENNIS MOON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOON
Provider First Name:
DENNIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235199845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 708850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84070-8850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-869-2395
Provider Business Mailing Address Fax Number:
801-352-9502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6644 E BAYWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-1747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-981-4391
Provider Business Practice Location Address Fax Number:
480-981-4624
Provider Enumeration Date:
03/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  30561 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 688921 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0718230 . This is a "BC/BS OF AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".