Provider Demographics
NPI:1144403791
Name:MOON, VICTOR A (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:A
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 1:233 E WACKER DR
Mailing Address - Street 2:#1402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5104
Mailing Address - Country:US
Mailing Address - Phone:917-686-4141
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:EMS 110, RM 3293
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244059208C00000X, 208600000X
IL036.123000208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery