Provider Demographics
NPI:1043788946
Name:MOON, CATHY
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3001
Mailing Address - Country:US
Mailing Address - Phone:215-845-0987
Mailing Address - Fax:
Practice Address - Street 1:1523 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3001
Practice Address - Country:US
Practice Address - Phone:215-845-0987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008900-1152W00000X
PAOEG003505152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist