Provider Demographics
NPI:1003208034
Name:MOON, TALITHA (DO, MPH)
Entity Type:Individual
Prefix:DR
First Name:TALITHA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 411 BOX 2481
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112-0025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SUDLAGER 301
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:92249
Practice Address - Country:US
Practice Address - Phone:314-590-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16272083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1627OtherNEBRASKA MEDICAL LICENSE