Provider Demographics
NPI:1073573093
Name:MOON, DAVID ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ROBERT
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
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 1239
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94302-1239
Mailing Address - Country:US
Mailing Address - Phone:650-815-5444
Mailing Address - Fax:
Practice Address - Street 1:409 FULTON ST
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-1326
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL30242085R0202X
HI117112085R0202X
CAG693942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2334750-00Medicaid
TX150799801Medicaid
TX84560RMedicare ID - Type Unspecified
MN300004821Medicare PIN
F80229Medicare UPIN