Provider Demographics
NPI:1043221443
Name:MOON, CHRISTOPHER A (DPM)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:A
Last Name:MOON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:54 S MAISH RD STE B
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-2824
Practice Address - Country:US
Practice Address - Phone:765-659-1843
Practice Address - Fax:765-654-5380
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000901A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000490972OtherANTHEM PROVIDER NUMBER
IN200465420Medicaid
IN1272900007Medicare NSC
IN193290BMedicare PIN
INP00334578Medicare PIN
INU76360Medicare UPIN