Provider Demographics
NPI:1245383504
Name:MOON, TIMOTHY H (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:H
Last Name:MOON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 KAPIOLANI BLVD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-4402
Mailing Address - Country:US
Mailing Address - Phone:808-946-7700
Mailing Address - Fax:808-946-7710
Practice Address - Street 1:1441 KAPIOLANI BLVD
Practice Address - Street 2:SUITE 312
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4402
Practice Address - Country:US
Practice Address - Phone:808-946-7700
Practice Address - Fax:808-946-7710
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD 450152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI49451801Medicaid
HI94-3274533OtherFEDERAL TAX ID
HIA20813-0OtherHMSA QUEST
HIA20813-0OtherHMSA
HI94-3274533OtherFEDERAL TAX ID
HIU64356Medicare UPIN