Provider Demographics
NPI:1235241100
Name:MOON, JAMES OWEN (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:OWEN
Last Name:MOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3400 HIGHWAY 78 E
Mailing Address - Street 2:412 MEDICAL ARTS TOWER
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8907
Mailing Address - Country:US
Mailing Address - Phone:205-221-5222
Mailing Address - Fax:205-387-0330
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:412 MEDICAL ARTS TOWER
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8907
Practice Address - Country:US
Practice Address - Phone:205-221-5222
Practice Address - Fax:205-387-0330
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL5798208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000019212Medicaid
AL000019212Medicaid
AL19212Medicare ID - Type Unspecified