Provider Demographics
NPI:1407387632
Name:MOONCAI, THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:MOONCAI
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 1:1 BOSTON MEDICAL CTR PL
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2908
Mailing Address - Country:US
Mailing Address - Phone:617-638-6800
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAF4228690-0039207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine